Patient care: make the purpose, choices and next steps understandable
Patient care connects clinical knowledge with a person’s needs, preferences and daily life. A useful plan explains what is happening, why an action is proposed and what follows. Clear communication is part of care itself, rather than an extra added after the technical work is finished.
Start with the person’s concern and the information needed
A clinical interaction establishes what is occurring from the person’s perspective and what is most important to them. A clinician and person may have differing primary issues. The act of listening aids in developing an assessment based on the needs of the person. In addition, the type of information required to develop an assessment may be beyond the results obtained from tests. The person must receive information that they can comprehend.
Write the person’s concern in everyday terms prior to translating into clinical terminology. Determine which portion of the concern was identified by the person (reported); determined by others (observed); or unknown. Consider how the explanation could be presented in a manner that is understandable to the person. The development of communication is critical in ensuring that people can identify and express their needs and preferences.
A decision needs benefits, harms and alternatives
Where there are several options available for addressing a specific issue or health condition, the clinical relationship should relate the research-based evidence to the person’s priorities. In addition to potential benefits, each option has associated risks. Uncertainty related to both options should also be addressed. Reasonable alternative options should also be discussed. While a decision aid or informational pamphlets may assist in supporting discussions regarding options available, these resources should not substitute for such discussions. People should be afforded opportunities to pose questions and gain clarity regarding what the proposed care plan entails.
Compare two fictional options using the same outcomes and timeframe. Do not present one option solely by highlighting the benefits and another solely by listing potential risks. Assess how the "practical" implications of each option meet the person’s current circumstances. When clinicians prioritize rationale (and rationale-based decisions), along with people’s priority lists, decision-making becomes clearer than when recommendations appear as "technical," unexplained recommendations.
Responsibility and follow-up should be clear
Care plans may include diagnostic testing, medications, supportive services, and review dates. Each component of the plan should contain a rationale (purpose) and a means for verifying completion. There should be a mechanism established for communicating results. If results fail to materialize, someone should take responsibility for determining cause and implementing corrective action. Tasks can be accomplished without resolving the broader question of care, therefore maintaining continuity among professionals requires consideration of subsequent actions.
To prepare for revisions, chart one investigative activity from collection through reporting and explanation to any subsequent actions taken. Identify who is accountable at each point. Such identification illustrates gaps within a care plan that are often masked by documentation indicating successful completion of tests. People typically have questions related to a missing result or an unclear instruction directed toward a particular service provider. These questions should be raised directly with those providers as opposed to attempting resolution through guesswork.
The account should preserve decisions and what mattered to the person
Documentation that includes findings, information exchanged, decisions made, and agreements reached facilitates future clinicians understanding key elements relative to previous care. Documentation of uncertainty is helpful when uncertainty impacts future care. The amount of detail included in documentation should be commensurate with the context of the care encounter. However, documentation containing personal information must include adequate protections. A signed form or a long record does not by itself demonstrate that someone understood the discussion.
Complete your teaching case by identifying agreed upon next steps, methods for reviewing said next steps, and routes for requesting assistance if new concerns arise. Routine appointments are not a justification for delaying assistance due to worsening conditions.
Check your understanding
A short quiz, with an explanation after each answer.
Why ask what matters to the person?
Return to the section you found hardest and explain its example without looking at the page. Check the explanation, then repeat the quiz later. Being able to describe the reasoning is more useful than remembering the position of a correct answer.