The Importance of Details

Hello all, I am currently on a rehab in the home placement and treated an interesting patient for the first time on Friday. In the interest of saving time during treatment, I like to gain a good understanding of my patients prior to seeing them for the first time so that I can develop a rough plan of what the session will entail. To gain this understanding, I must rely on reading the notes of other health care professionals.

Prior to seeing this particular patient, I had read a summary of his problems from the notes as follows: Current problems/diagnosis- 91 yr old patient had just been discharged from hospital following a 9 day hospitalisation following constipation. As a result of the hospitalisation, he had become quite deconditioned and needed physio input to increase his exercise tolerance, balance and strength. Past medical history was stated simply as: falls, DVT, hip dislocation, leg length discrepancy (compensated by raised shoe). Considering the complexities and comorbidities of a lot of elderly patients around this age that I had previously come across, this patient sounded quite simple!! I planned to do my subjective and then objective, including a functional assessment of the client in his home, balance assessment, gait assessment and a couple of simple objective measures like the TUG and Repeated Sit to Stand. My rough plan for this initial treatment was some walking, basic strengthening exercises like sit to stand, heel raises, etc and perhaps some education about how to get up off the floor.

When arriving at the patient's home I quickly realised how non-simple the patient was... that "hip dislocation" mentioned in the PMH turned out to be hip dysplasia that the patient has had since he was 3 yrs old (ie the hip is still dislocated and always has been!), meaning functionally the movement and strength in that hip (and entire lower limb) is pretty minimal and it was fixed in flexion. On top of this, the "leg length discrepency" mentioned in the PMH (which I imagined was fairly minor) was actually a 10cm discrepency due to the hip dislocation! As a result the patient had a gigantic, heavy custom-made shoe which he had to wear whenever ambulating (for those of you who have seen Summer Heights High... think Pat, the rolling lady from Perth). All of a sudden my plan had to be changed quite significantly- the patient always took the shoe off when sitting and put it on again once standing- this meant measures like TUG and Repeated Sit to Stand were useless because the patient would spend most of the assessment taking his shoe on and off. My treatment too, had to be completely re-considered.

This situation raised 2 important issues- the first being note writing: as health professionals, we all need to understand that our notes will be read by others, and should offer an accurate picture of the patient and their progress. Obviously patient notes cannot be too detailed, otherwise we would never have time to actually treat patients, but within reason, the important details should be written. Providing a hand-over to another therapist who has never seen the patient before is often difficult. Because you are so familiar with the patient, it is hard to imagine reading the notes from the other therapist's perspective who has no prior knowledge and as a result, often we can neglect to mention important details. A simple modification to the PMH notes I read could have been "Permanent hip dysplasia since age 3 yrs with resulting 10cm leg length discrepency and minimal hip function". Even a simple change like this would have offered a more accurate clinical picture and consequently made that first treatment session run a lot smoother.

The second issue is treatment planning: having a rough plan prior to treating a patient can definitely help the session run more efficiently and give you a greater sense of confidence, but you should always be prepared to be flexible! We must be prepared that we may have to completely change our plan depending on various patient/therapist factors, and not panic in the process.