PATIENT CASE SUMMARY GUIDELINES

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1 7 PATIENT CASE SUMMARY GUIDELINES PATIENT CASE SUMMARY Please use the following template as a guide for your SAPOC and Community Care write up: Your Name Module Module start date - Module end date Heading Patient Case Summary Please use the Helvetica or Verdana font, 11 point, single spacing REFLECTION ON PROFESSIONAL PRACTICE PRINCIPLES Use the following to guide your writing: Describe what happened What were your reactions, feelings or thoughts about it? What did you learn from this? What further learning do you think you might need to do in relation to this? How might you do that? Please use the following template as a guide for your reflection: Your Name Module Module start date - Module end date Heading Reflection on Professional Practice Principles Please use the Helvetica or Verdana font, 11 point, single spacing This is an in-course requirement for award of MBBS. You should have completed TWO case reflections by the end of your attachment one in each of SAPOC and Community Care. You will need to meet with your clinician at the end of your placement to discuss what you have covered and to agree a grade of pass or referred. Some tutors will do this as part of a group session whilst others may want to meet with students individually. Your Clinical Supervisor will read your write-up and grade it as part of the placement assessment. If you fail it you will need to redo it in subsequent attachments.

2 8 To pass you are required to show that you have adequately summarised a patient case and that you have considered some examples from each of the five professional practice principles. You need to reflect and evaluate your learning with respect to these principles. If you fail it you will need to redo it in the next attachment. PRINCIPLES OF PROFESSIONAL PRACTICE: (FROM CORE COMPETENCIES FOR FOUNDATION YEARS GMC 2005) Below is a list of the principles with some explanation of what they mean. We have also included a table below which gives further examples of things you might include. Examples of write-ups including some from previous years students to illustrate the type of summary and reflections that we are expecting from you are given below. 1. Good Clinical Care. Doctors must practice good standards of clinical care, practice within the limits of their competence, and make sure that patients are not put at unnecessary risk. Health professionals must do their best to provide best care for the patients whom they look after. Whether they are a staff nurse, junior house officer or consultant, they need to work within their own limitations and understand when they may need to seek advice from a colleague or senior member of the team. Did the patient you ve selected receive what you believe was good clinical care? Reflect on what was good and why you think it was but also any way in which the clinical care may have been improved? 2. Maintaining Good Medical Practice. Doctors must keep up to date with developments in their field and maintain their clinical and non-clinical skills. Doctors are obliged to keep up to date with current medical practice and need to find opportunities to further their medical education. They can learn from audit how to change clinical practice for the better. There are a number of ways in which this can be done. Either in relation to yourself or someone with whom you have worked, describe how you/they achieve this responsibility. Identify your additional learning needs with regards to the patient or their medical condition. Describe how you addressed these. Is there anything you have learnt about how the system of care is organised that affects clinical practice? 3. Teaching and Training. Doctors have teaching responsibilities to colleagues, patients and their relatives. They must develop the skills, attitudes and practices of a competent teacher. The training that we receive and the teaching we provide are the cornerstone of maintaining high quality patient care. Give an example of

3 9 such, either as a learner in receipt of teaching, or if you have taught or given feedback to others, you can describe this. This may be more difficult to relate to a specific patient. However you could reflect on how the patient helped you learn and how you might teach a colleague something relating to the patient. For example how could you plan a clinical teaching session relating to the patient. 4. Relationship with Patients. Doctors must be able to develop, encourage and maintain successful professional relationships with their patients and widely understand the patients expectations and experience of care; their practice should reflect such understanding. Good clinical care is not simply about diagnosis and treatment; our relationship with the patients that we look after is tantamount to the trust that they have in the health system and those providing their care. Discuss the interaction you had with your patient. If it went well what are your reasons for thinking so or if the interaction was problematic discuss why and how things might have been approached differently. Compare this to the relationship that another team member had with the patient. 5. Working with Colleagues and in Teams. Doctors must work effectively with colleagues in medicine, other health-care professions and allied health-care workers. They must be able to work as effective team members. Our working environment is important and this relies heavily on the professional relationships that we have with colleagues and the communication between us. This includes not just other doctors, but the whole multi disciplinary team looking after the patient: radiographers, porters, physiotherapists, lay volunteers, consultants. Discuss the way the team looked after your patient. Discuss both positive aspects of the teamwork and suggestions on how it could be improved. Additional principles listed by the GMC which you do not need to write about are Probity* (Doctors must be honest) and Health (Doctors must not allow their own health or condition to put patients and others at risk). *NB In doing this portfolio you should abide by the principle of probity. Plagiarism will be regarded as a serious breach of probity.

4 10 PATIENT CASES AND REFLECTIONS ON PROFESSIONAL PRACTICE PRINCIPLES Good reflective practice is a core part of any learning programme. Being able to identify your challenges and discuss them with your supervisor will help you define future learning opportunities and apply what you re learning in the work environment The Foundation Programme 2007 What you are required to do Choose TWO patients (one during each placement Community Care and SAPOC). You can select which patient although it is recommended that you choose a patient that your Clinical Supervisor knows, to maximise the usefulness of your discussions. This work will be reviewed and discussed with your Clinical Supervisor at the end of each of your clinical attachments and will be included in your end of placement grade. Aim to write a total of about 1000 words, either typed or legibly handwritten for each of the TWO patient cases. This will include: A summary of the patient in the form that would be used for handover to a colleague. You should keep this to one paragraph A reflective discussion section addressing Principles of Good Medical Practice. Over the TWO cases you select you need to ensure you cover at least two principles for each case What to include in your write-up We want you to reflect on your own experiences as much as possible rather than observing others, as this will improve your own self-awareness. The examples you take can be either good practice or poor practice (or a mixture). The important thing is that you demonstrate ability to reflect and show what you have learnt from these experiences and can identify further learning needs. The Foundation Programme Learning Portfolio suggests these questions to guide your reflection: Describe interesting, difficult or uncomfortable experiences. Try to record both positive and negative elements; What made the experience memorable? How did it affect you? How did it affect the patient? How did it affect the team? What did you learn from this experience and what (if anything) could you (or others) do differently next time? Confidentiality of patients and colleagues names should be maintained throughout the portfolio.

5 11 PRINCIPLES AND EXAMPLES: WHAT YOU MIGHT INCLUDE 1. Good Clinical Care Ability to diagnose patient problems Ability to formulate appropriate management plans Awareness of their own limitations Ability to respond to psychological aspects of illness Appropriate ordering of resources e.g. ordering investigations 2. Maintaining Good Medical Practice (Learning Skills) Ability to manage time effectively/priorities Technical skills (appropriate to current practice) Ability to be self-directed; request feedback; act on feedback Audit 3. Teaching and Training Willingness and effectiveness when teaching/training colleagues Giving feedback to others/ Peer review Sharing good practice (case management discussions, grand rounds) 4. Relationships with Patient (Communication and Interpersonal Skills and Ethics) Communication with patients, Communication with relatives and carers and/or family Respect for patients and their right to confidentiality (e.g. Involving patient in therapeutic management decisions) Professional relations and boundaries with patients, respect and avoiding overfamiliarity Working with cultural, social, ethnic difference, disability Managing own and others emotions Dealing with difficult and violent patients Advocacy for patients or community/interpreters Handling complaints Patients rights (Consent, confidentiality and truth-telling) 5. Working with Colleagues and in Teams Verbal communication with colleagues Written communication with colleagues Ability to recognise and value with the contribution of others Accessibility/Reliability

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