rotation 4 stares entry 1: communication

Situation:
I was asked to see a 48 year old aboriginal gentleman on my ward. He was admitted with an infected stab wound to his left thigh, he was sent to surgery the next day to wash out the wound. The medical team were keen to discharge this patient the day after his surgery and I was asked to assess his mobility to determine whether he was fit to be discharged. On assessment he currently was not at his premorbid level of mobility which was independent ambulation with no aids. He currently is ambulating independently with a wheeled zimmer frame secondary to pain; I was also informed by the patient’s social worker that as this patient is deemed “functionally homeless” he can not be discharged with a wheeled zimmer frame.

Task:
Effectively document and communicate to the medical team outlying why the patient currently can’t be discharged.

Action:
I wrote in the integrated notes in SOAPIER format to detail the patient’s current level of mobility and the factors in which were contributing to his current decline in mobility leading to this patient not being fit for discharge.

Result:
The medical team understood the reasons I gave them for why this gentleman could not be discharged and took my advice plus were able to look into accommodation solutions for this patient.

Evaluation:
My notes were a little unorganised and could have been a little more specific on the causes why this patient couldn’t be discharged, i.e.: reduced mobility due to pain. I think I reiterated well in my notes that the patient was not ready for discharge due to his mobility status affecting his social discharge.

Strategies:
• Clearly explain the reasons why the patient can’t be discharged.
• Have notes written in an organised manner so they are easy to read.
• Make it clear in the notes that the patient is not ready to be discharged.