Entry 3

Situation: In my previous journal entry I spoke in detail about the annual physiotherapy assessments that Rocky Bay clients receive. Equally as important as the assessment itself is the report that accompanies it. The report must include a subjective section detailing things such as mobility and transfers, school and physical activities. It must also include a respiratory, postural, gait, functional ability, muscle strength and joint range of motion assessment along with a detailed analysis of the assessment itself and a plan for the future. With all these requirements it makes for quite a lengthy report and is a time consuming process as well. Last week I had a young man with Friederich’s Ataxia come into Rocky Bay with his mother and I was booked in to perform his annual physiotherapy assessment.

Task: My task was to perform the assessment that afternoon and although I didn’t have a set time frame, I set myself a goal to have the assessment report completed by the end of the following day. The reason I wanted to do this, was so that the assessment was still fresh in my mind and I could give myself every opportunity to write a good quality report.

Action: I conducted the assessment without any dramas that afternoon and because I’d had a bit more practise and developed some better techniques I was able to complete it in under an hour and a half, which I was pleased with. This meant I had a bit of extra time up my sleeve to get started on my documentation that afternoon. The following afternoon after having a pretty busy day I had almost finished my report. I had entered all the necessary numerical data such as muscle strengths and lengths, and done postural and functional ability descriptions so just needed to complete my analysis and I was done. Despite having done a few before, I was finding this one a bit more difficult because there wasn’t many major or significant changes compared to the previous assessment findings.

Result: The result was that I ended up viewing the analysis from the previous report to give me some ideas on how I could get started. I managed to get some good points that I was able to modify to suit my current assessment findings, but at the same time noticed that it was quite a detailed analysis in the previous report. It was certainly more detailed than those I’d done in the past, so I adopted this method and made my dot points more detailed before finishing off the report. I then notified my supervisor that I’d finished the report and asked her to have a read before I submitted it into the system. My supervisor said I’d done an excellent job with the report, but did give me a few pointers on things to improve for next time. One was that I don’t need to go into such detail in the analysis and that some points weren’t really necessary, which I was a little shocked to hear considering it was what I’d read in the previous one. I responded by telling her that it was last year’s document that I had read and had given me the impression that it was how I should be doing it, and subsequently thought I should do the same. Her response was that she could see I had done my own analysis, she just didn’t want me to write as much in the summary section of the report and that in the future I shouldn’t copy what I see on previous reports. She also gave me a few additional tips for the future.

Evaluation: In evaluating this process I feel that everything went really well except for the analysis in my report. I conducted an effective and efficient assessment and wrote a detailed and accurate document and was quite proud of my work. I don’t even feel that my analysis was really that bad. If I was going to be criticised for something, I’d prefer it to be for being too detailed and thorough than too brief. I feel that my supervisor brought the point up more because of the principle of the situation in stopping me from getting into bad habits by always reading the previous reports and potentially not thinking about things for myself. I know that I didn’t blatantly copy the previous analysis, rather I used it as a template to guide my own efforts, but I could see exactly what my supervisor was saying. I also understood that the analysis of the assessment didn’t need to be so detailed, as it was almost repeating my findings from the assessment, it should be used more as a summary section in this situation.

Strategies: My supervisor’s suggestion was that in the instance where I’m having trouble with an analysis, I should write some brief notes that I want to include and then once I’ve done this view reports from previous years. In doing this, I have my own opinion and have some additional information with which to make further judgements as to how I want to write the final edit of the analysis. Another strategy that I used regularly after this event was simply to write down the main headings from the report and then write a note about the most significant finding under this heading. For example under the heading of muscle strength I could input the information that overall hip strength findings decreased from grade 4’s in the previous assessment to grade 3’s currently. By using this system I never had any further problems with formulating the analysis section in my reports. The other thing that immediately came into my mind after this scenario was the importance of making your own clinical judgements and not simply relying on you what have been told by another source. This may come into play when receiving a referral from another health care professional who may have made a diagnosis on an individual you are about to see. It’s important you make your own diagnostic decision in regards to the individual because the previous person may have got it wrong and it is you who has to treat them. Consequently it would be you who would pay the penalty for providing treatment for the wrong condition or case, so it’s always important to formulate your own clinical judgements about the current situation confronting you.