The basic consultation11 When a patient sees a medical professional such as

Table of Contents

The basic consultation1.1. When a patient sees a medical professional such as a Health care Assistant, Advanced Nurse Practice or a GP, identification must be confirmed from both medical professional and the patient, this is so there is not a breach of mistakenly given the wrong information or procedure to the wrong patient, For example of confirmation of identity could be:Doctor: Hello I am Dr X and you are?Patient : Hi Doctor Im John SmithAt that moment identity has been established between medical profession and patient.1.2 Provide and introduction of self and role When introducing yourself to a patient the 5 P’s come into consideration – Preparation- Precedence- Pronunciation- Pattern- Parallels Furthermore When meeting a patient, it is important to let the patient know of your role for example I am Dr. Smith I am an orthopaedic surgeon and I will be preforming your hip replacement, making eye contact with the patient will and extending your hand, if the patient has brought family to the appointment then the GP will acknowledge them too.1.3 Present complaint When having a consultation with a patient there are steps to follow to ensure the appointment runs smoothly because this is where the patient will tell you of their problems for example: Back pain . the steps are as follows – Step 1: Introduction- Step 2: Presenting complaint- Step 3: History of presenting complaint gaining as much information as you can, such as:• Site – Where is the pain• Onsent – When did it start• Character – whats the pain like• Radiation – does it move anywhere• Associations – any other symptoms such as Sweating, vomiting• Time course- does it come and go and if so how long• Relieving factors – does anything relieve the pain• Severity – using a pain scale- Step 4: Past medical History- Step 5: Drug History- Step 6: Family History- Step 7: Social History- Step 8: review of systems e.g MCAS, GI, Neurology- Step 9: Summary of History- Step 10: Patient Questions1.4 Understanding Medical HistoryWriting down the medical history from the patient is an essential part of being a effecting GP:- It identifies how the illness has progressed to date- Establishes the doctor-patient relationship- How the illness and affected the patient and the family- Explores the patients concerns and ideas about the illness and the doctors expectations- Identifies the patients physical, social and psychological environment- Can lead to diagnosis.1.5 Undertake basic clinical observationsYou’ll spend a lot of time with patients/clients in your role as part of the health care team. This means you’ll have lots of opportunities to observe your patients/clients, to monitor how they’re progressing and to spot any problems early.Part of your observing and monitoring will involve using a set of clinical skills that we’re going to look at in this section. Understanding how to, for instance, assess patients’/clients’ breathing, pulse rate, blood pressure and body temperature, and what your assessments mean for their welfare, are key skills you’ll acquire. We’ll also look at supporting medication tasks, which may be something you will have an opportunity to do in your workplace. is probably no exaggeration to say that the main reason for all of these observations is to spot a change in the patient’s condition quickly and accurately – a rise in body temperature that might denote an infection, or a reduction in the amount of fluid taken that might indicate a general deterioration, for instance. We then report these observations to the registered person in charge and he or she is able to determine the next steps – whether to escalate concern to the rest of the team, or continue (or increase) the observation schedule.But we don’t need to rely on specific times and specific activities to observe for changes in patient’/clients’ conditions. We should be observing all the time for these changes.Many things that happen to patients/clients that might indicate a change aren’t necessarily captured in formal observations. You might notice that a baby is taking longer to feed than normal, a child is more reluctant to play or eat, an older man is going to the toilet more frequently than usual, a wound dressing seems to smell stronger than it did the last time you looked, a patient who is unable to speak is grimacing and writhing in his seat, a person who has experienced depression in the past seems to be becoming a bit more withdrawn. Some of these things may not be significant, but some may highlight a change in condition that requires closer examination. By constantly using your eyes, ears, nose, touch and knowledge of what is ‘normal’ for the people you care for, you can identify potentially serious changes early and, by reporting them to the registered person in charge, make actions taken to counteract them more effective.1.8 Signposting1.9 Chaperone Common key lines of enquiry2.2 – Demonstrate an understanding of smoking, alcohol & exercise Exercise provides lots of benefits to the brain and the body, it can be regarded as a protector against disease. Patients also engage in healthy behaviour such as having a sufficient sleep, and nutritious diets are going to be far healthier and also have less health problems than someone who doesn’t exercise. In contrast to exercise, alcohol is not regarded as health promoting behaviour, however by having a moderate intake has been shown to have a lower risk of cardiovascular disease. Furthermore several large population based studies has shown to have a positive association between alcohol intake and physical activity. The link between smoking and alcohol has serious implications for those who are in treatment for alcoholism. Many alcoholics smoke, which puts them at a high risk for tobacco related complications for example, cardiovascular disease, lung disease and multiple cancers. Some statistics suggest that more alcoholics pass away from tobacco- related illness, than however alcohol related problems. Furthermore understanding how tobacco and alcohol interact is challenging, this is because co-use is very common, and furthermore both substances work with the similar mechanisms in the brain. 2.3 When filling out forms at your GP surgery there will be some questions whether if your grandmother had high blood pressure or diabetes. Patients medical history includes both your family health and your personal health, within your personal health history will have any health problems you’ve ever had. A family health history will have details about the health problems your blood relatives have had during their lifetimes. The information will give your doctor important clues for what the problems to your health are, this is because various diseases can run in families. The history will also tell your doctor what health issues the patient may face in the future. If the GP learns that both of the patient’s parents have cardiovascular disease, the GP may focus on your heart health when you are younger than the other patients who do not have a history of cardiovascular disease. Every patient should know about their family health history. The patient may or may not know some information regarding the conditions that are affected each different family members. It is always best to double check of what you do know. By finding this out is by asking as many blood relatives and this is including half brothers and sisters. 2.4 When recording family history it is important to the patient they have a family member of cardiovascular and diabetes are a higher risk that 2-5 times higher than of the general population. However a positive family history reflects on the inherited genetic susceptibility and that is also shared with environmental factors and behaviours that are within the family. Family member histories are associated with a higher risk of disease when there is multiple family members that are affected. When the affected family member that are first or second degree relatives, also when the disease occurs at a young age. The basic or more specific risk provisions are used to develop the guidelines that are customized for each risk group. Furthermore in high risk patients genetic counselling and testing can be considered. The family history is useful because it can be used to evaluate the possibility of mutation within the family. Patients that do have an increased risk should benefit from a screening and prevention programme, similar to those who have colorectal or breast cancer. The family history should be reassessed frequently; this is because family history can change over time. 2.5 Obtaining an accurate medical/drug history is one of the first steps of the reconciliation process. This is histories that consist of all medicines which are prescribed and bought over the counter which the patient will be taking before their admission into hospital. Furthermore the patient should tell the GP their allergies or that if they are sensitive to certain medicines, so the GP could prescribe alternatives. Also recently stopped medicines which can be in the last month or so. And finally short courses of antibiotics and corticosteroids should also be noted in the patients’ medical history, some medical conditions a list of medicines that have been trailed should be included also in order to help prescribing in the future. Traditionally when obtaining a medication history has been dealt with solely by GPs, however recent times have now pharmacists and trained pharmacy technicians now play a role in this process, without an accurate medication history, the health professional who is seeing the patient may make an incorrect decision about a patients treatment, making an incorrect decision can cause some harm to the patient if the medication has been discontinued then restarted.2.6Be able to implement and promote active participation3.1. Describe different ways of applying active participation to meet individual’s needs.By helping patient achieve their goals, this is not by doing the tasks that have been set up for the patient to achieve these goals but through assistance and guidance, this is therefore giving the patient their own independence. This is enabling every patient to take part in activities and relationships no matter of the patients ability or excluding them because you would feel that it would take up too much time, or the patient will be a hindrance to your day.3.2 Work with an individual and others to agree how active participation will be implemented.By encouraging patients in conversation it is giving them choices and by providing them the idea and information for the patients to think for themselves, furthermore explaining to patients that who are reluctant to allow active participation and the benefits of carrying out active participation. For patients who understand the importance of active participation, it could be useful for the patients to be explained the benefits especially if they are close to the patient who needs the encouragement to become active.3.3 Demonstrate how active participation can address the holistic needs of an individual.From looking at the whole patient of their situation is holistic, this is not just the task in hand, for example, it is not just feeding a patient so they get the nutrients they need but however by allowing the patient to choose that they would like to eat, by allowing the patients to feed themselves in an area that they feel comfortable eating, so you are making sure that the patients are comfortable in every way that is emotionally, mentally and physically as much as you possibly can.3.4 Demonstrate ways to promote understanding and use of active participation.Usually the patients that do not understand the importance of active participation are usually a close family/friend member, also however the patient themselves who need to be actively participating, by explaining the beneits to the patient and to their friends and family and provide evidence where possible to a patient who has made an achievement that could be very big or very small.Be able to support the individual’s right to make choices4.1 Demonstrate ways to promote understanding and use of active participationThere are various ways we can support a patients needs to make informed choices, it is important as a clinician that their not judgemental, when communicating, empowering and to encourage the patient to make informed choices, by also respecting the choice as well as a result will be supporting them to question or to challenge the decisions that are concerning the clinician that is made on their behalf. 4.2 Use own role and authority to support the individual’s right to make choicesBy using your own role to support patients choices you must ensure that the patient has all of the information that they need in order to make that informed decision, by doing it in a way that the patient can fully understand. The clinician will also weigh up all of the positive and negatives outcomes from each decision which could be made for the patient. However if you are not unable to provide the information that is needed for the patient to make a decision then the patient will be directed to someone who is able to help the patient and to be trusted as such which can be a GP, nurse, HCA or clinical pharmacist. These clinical staff are impartial to the emotions that may affect the making of the decision, furthermore by also making the decision that is in the best interest of the patient and not those family/friend members who are emotionally involved.4.3 Manage risk in a way that maintains the individual’s right to make choicesManaging risks can be used by creating a risk assessment, and that is a process that is made up of evaluating and identifying a risk and the possible consequences that might come from the risks. This can be done by identifying the risks that are involving in partaking for example, we may want to decide that if the risk is worth taking, and to evaluate and record the findings as choices, this can be decisions about care or treatment. The impact that may have on the awareness of likelihood and actual hard/danger that may possibly rise from the choice that the patient has made, whether it can increase or it will decrease that patients vulnerability.4.4 Describe how to support an individual to question or challenge decisions concerning them that are made by othersWithin working in general practice it is important to encourage questions, this can be through discussions and to be prepared to listen and ensuring that each patient is aware of the practices policies and procedures, complaint procedures, the awareness of the advocates that are available to them and to have the option off a second opinion, finally it is important that the patient is aware of their own rights.Understand the principles of person centred assessment and care planning5.1 Explain the importance of a holistic approach to assessment and planning of care or support within general practice. The importance of a holistic approach for the planning of care or support within general practice, is mainly more for the patients that have individual psychological and physical needs, likes and dislikes, culture, family and friends and spiritual beliefs. The person centred approach is a method that is linked with the active participation method, which is used in a way of working that will recognise the patients right to be able to participate in the activities and the relationships of every day and to be independently as possible, the patient is regarded as active partner in their own support or care, rather having a passive patient. 5.2 Describe ways of supporting the individual to lead the assessment and planning processWithin General practice, a planning process means how the care needs for the patient will be provided that is according to the patient’s plan of care assessment. The planning process will ensure that there is good delivery of the care needs that is according to the patients’ health history, preferences and wishes regarding the care needs as documented to the patients plan of care assessment, A planning process can set how the care needs are going to be provided day to day.5.3 Describe ways the assessment and planning process or documentation can be adapted to maximise an individual’s ownership and control of it.Within general practice the ways in assessing and planning process of the documentation that can be adapted to maximise a patient’s ownership and the control of it. Meaning that the staff works in a active participation and a person centred approach. Furthermore by promoting a person centred approach that will include the patient requiring further support or care at the heart of the planning process, this will also promote the active participation by enhancing the patients wellbeing by being part of a team.In order to maximise an patients ownership and control of the planning and the assessment process or documentation, that they are adapted to the patients preferred method of communication and their preferred language. Thus meaning that staff ensure that person centred values, furthermore working in a way that is able to promote person centred care through person centred thinking, person centred reviews, person centred planning and family centred care, this means that staff to provide the care needs that are respectful and responsive to the patients values, needs and preferences.By ensuring that the patients values guide all of the care need decisions that is according to the patients cognitive impairments, this will mean that the staff that are doing everything that they possibly to ensure that the patient does understands the assessment, planning process or documentation. Furthermore this will ensure that custom care needs i.e. the planning, the assessment or documentation can be adapted in order to maximise a patients control and ownership of it. Another example of this is the staff using communication albums such as books/magazines with large font and pictures, (aid memoir daily life communication, aid memoir personal communication, aid memoir medical communication, aid memoir food communication) that will describe the questions of the choices to be enable the patients that does lack mental capacity, such as patients living with dementia or Alzheimer’s to understand the planning process, assessment or documentation.