Sorry this is so close to the last one! Have had some trouble connecting to the net this week. During a recent placement I was given a handover for a patient on a ward I was unfamiliar with by the ward physio. The handover the physio gave me was given to them by the nursing co-ordinator for that shift – in both instances neither had actually met the patient. Included in this handover was the following, patients ages, PC, brief HPC, PMH and brief social situation. From this handover it appeared that this patient was relatively straightforward and required a mobility assessment and possibly chest physio. With this handover I allocated a certain amount of time to see the patient and went to the ward to treat them. As with all patients I read through their notes prior to seeing them and very quickly identified a number of significant events that were not present in the handover;
1. Patient had been in ICU for a period of time requiring ventilation
2. Patient had had a recent code blue on the ward (when ambulating)
3. Currently the patient was in ARF and not medically stable
4. Doctors on the ward round that morning had indicated in the notes that the patient was to be RIB for the next 2-3/7 thus not appropriate for PT
After reading through the notes I realised how important it is not just to take the information given by others prior to seeing a patient without having investigating their history yourself. While some of this information probably should have been included in the handovers the nursing co-ordinator and physio are by no means at fault (as they didn't know the patients full history either) but it really highlighted to me that you need to have a fairly good understanding as to the patient’s background prior to seeing them. In this case it was very obvious after reading the notes and was re affirmed by my supervisor that this patient was not appropriate for PT Rx. When you’re busy on the ward and don’t have much time to read through the notes it can be easy to just go by the handovers you receive (I have definitely been guilty of that!), but this particular patient has shown me that without reading their notes I could have potentially caused a medical emergency for this already acutely ill patient just by taking a shortcut. Thus even though it may take an extra few minutes you don't have, find the time to read through the notes as it may save your patients life!
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That is definitely a good point you make. I have found on my pracs that each hospital seems to have a different policy in regards to handovers when a pt changes wards. On some pracs I have been given a concise verbal handover, others a very short written handover via page and on one prac no handover at all! As you say, regardless of the handover it's still really important we check the pts notes for ourselves to be safe.
Yep, agree entirely Erin. Even if given a handover, and regardless of how thorough it may be, it is our obligation if we are going to treat the patient, that we read their notes ourself. Something always could have happened from the time the handover was given and the time that you see the patient. I know that I always feel more confident seeing a patient having a thorough understanding of their status. Even if as you mentioned you are pressed for time, I’d rather cover my self but being sure of the patient before doing anything. I’d hate to think a situation would arise and someone had to go to court because their assessment/treatment was not indicated for the patient and the therapist was too lazy to read their notes before seeing them.
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