1. Clinical examination and the written record
Contents
What does clinical mean?3
The clinical record4
The clinical history5
Recording the examination8
This book offers an approach to the management of patients with minor injuries. It aims above all to answer the demands of the acute clinical setting where such patients usually present. In Emergency Departments, Minor Injury Units, Walk in Centres and other places where patients arrive with undiagnosed problems which may or may not be injuries, and may or may not be minor, there is a need for a working method which is robust, flexible and swift.
Doctors learn as students to take a clinical history, examine the patient and make a written record of their findings. However, many of you who are now treating patients with minor injuries are not doctors and you may be less familiar with the clinical method.
The clinical record is not only a written note of your encounter with a patient, it is the template for the physical process of talking to and examining the patient. The written record and the actual examination are not the same thing any more than a river bed is the same thing as a river, but they can reflect each other in a similar way. Each consultation can be as well structured as the record, and each record should describe every important thing that was said and done or not done during the examination. The written record is not just a note of what has happened, it is a reflection of the method and the sequence which you follow with the patient and the diagnosis should flow logically from it.
What does clinical mean?
The word clinical is used daily in hospitals and health centres everywhere. What does it actually mean?
The word is encrusted with medical associations, tiled rooms, examination trolleys, white coats, cleanliness, and certain smells. These associations can evoke the common fears they seem to be designed to suppress, of pain, loss of control, decay and death. In the spirit of those impressions, clinical examination is a term which has come to have rather impersonal associations, of a technical process carried out by an expert ‘clinician’ on a passive agent, the ‘patient’. Indeed there is an alternative terminology for the history taking and examination phases. They are called the subjective examination and the objective examination. This terminology implies the unreliability of the patient’s perspective and the clinician’s detachment.
The root of the word ‘clinical’ is more homely. ‘Klinikos’ is the Greek word for bed, and clinical activities are those which happen at the ‘bedside’ between you and your patients as you try to find out what is wrong with them.
Clinical examination is a two-stage process, a conversation between you and the patient and an examination by you of the patient’s body, which is based upon that conversation.
The conversation, or the history, is at the same time a social interaction using all of the skills which ordinary conversation requires, and a professional encounter with a clear objective. For a good outcome it depends upon communication skills, empathy, keen observation and the ability to listen. Physical examination is a more obviously technical process than taking a history, but it cannot be done without the trust and cooperation of the patient. Interpretation of your findings is a matter of skill and experience. In all of this the relationship with the patient is the lynch-pin
The objective of the clinical process is to discover what is wrong with the patient, to reach a diagnosis. Diagnosis is another word which is derived from Greek, and means ‘knowing one thing from another’. The information from the clinical examination may lead to further actions before or after diagnosis. These may include investigations to clarify the diagnosis, and treatment or referral to another clinician.
When patients with minor injuries require investigation, X-ray is almost always what is wanted. The menu of further investigations is limited. Clinical examination is therefore the chief tool and the chief skill which must be mastered, for the diagnosis of minor injuries.
The clinical record
The written record of the clinical examination has two important functions:
• It is essential for continuity of treatment for your patient. The GP has ultimate responsibility for the integration of the patient’s medical care, and should receive a report on any treatment which he or she has received.
• It provides evidence, acceptable in a court of law, of what happened during the examination. Patients who are treated for acute trauma occasionally come to the civil or criminal courts. Patients may come to court to sue you, or your employers, if they feel that you have been negligent in your care. The court will most easily be able to accept your account of events if a written record, made at the time of the episode, supports your later statements. Your motto should be: if it is not written, it did not happen.
The written record has other uses. It carries data which can be used for audit. Electronic patient records allow increasingly sophisticated ways of retrieving and auditing information. The use of confidential patient information must accord with the rules governing both the ethics of research and data protection laws. You can obtain information locally about the management of such issues in your area.
The value of the template of the written record to organise the physical process of examination has already been discussed.
The double status of the written record, as a medical and as a legal document, means that it must conform to certain standards.
1. Identify the patient by full name, date of birth, address and CHI number if that is available. If continuation sheets are used, record the patient’s name and date of birth on each sheet.
2. Note the date and time of attendance, as well as the time of triage, if that occurs, and the time of starting and ending the consultation: if the patient is seen more than once, record the date and times of each visit.
3. Sign the notes and write your name and designation in capitals below the signature. Anyone who writes on the sheet should sign it. This may be, for example, another practitioner, a nurse who has checked a prescription or a radiologist who has recorded an X-ray report.
4. If the treatment sheet is handwritten, it must be legible. Write in black ink and use abbreviations only if they are widely understood and unambiguous.
Technical language
It should be your aim to write a clinical note as simply as possible. However, ordinary language does not always give you words which are clear enough to say what you need to say, and you may need to use some kind of technical language.
Technical language refers to words which are either not in common use or are common but are used in a special way. It may help you in your professional communications, but be aware that patients do not understand your jargon. Detailed advice to patients on the management of injuries and health promotion is a vital part of your work. A lot of the medical language which causes problems (words like trauma, fracture and sprain) inhabits a middle-ground where many patients understand it, but others do not. Assume nothing and ensure that you are understood.
The technical language used belongs to one of five categories:
1. anatomical terms for parts of the body
2. terms which describe the movements of parts of the body
3. terms which describe the position of one part of the body in relation to another
4. ways of describing where on the body a lesion is to be found
5. types of injury.
Anatomical names are not always necessary. The everyday equivalents are often just as precise as the Latin (knee-cap for patella, collar-bone for clavicle, shoulder-blade for scapula and so on). Many Latin names are widely known, especially among sportsmen. However other everyday words such as stomach are often used vaguely, so that it may not be clear whether the patient has chest pain or a problem in the abdomen. Shoulder, as the word is commonly understood, describes a group of joints, and a more exact description is sometimes needed.
Everyday language is not good at describing positions and movements of the body. To say that an injury lies below the wrist, when the hand can be held above or below that joint, is unclear. The outside of the hand can be any surface, depending on how the arm is rotated. To say that the patient’s finger, wrist or ankle hurts because he twisted it does not give a picture of the exact movement. That picture is needed to narrow down the range of injuries which might have occurred.
Pay attention to simple matters. Record whether the right or left side is affected, whether an injured digit belongs to the hand or the foot, and which joint of a finger is painful. The standard to aspire to is that a person who reads the account later, when the patient is not present, can reconstruct every important fact.
Diagrams
A treatment sheet will probably contain a space for a diagram, and certain injuries, especially wounds, lend themselves to pictorial representation.
It is not necessary to be an artist to do this. It is fine to draw a bunch of bananas, but you must label the picture so that the reader knows whether these are hand bananas or foot bananas. Label it even if it appears to be totally clear to you, saying left or right, front or back, naming the body part and sketching the injury. Some treatment sheets provide diagrams of the body and there are also rubber stamps available which depict all parts of the body.
The terminology which is necessary for describing injuries will be included at the appropriate places in the text.
The clinical history
The taking of a history is a social act, a conversation, and it calls for the skills which mark the conversationalist, warmth, empathy, listening and a grasp of the nuances of unspoken communication. However, it is not a casual conversation. It occurs in a very unequal situation. You are in control. The patient needs help and is vulnerable.
You will develop your skills at eliciting the history as your career progresses. It can be rather depressing for a beginner to read a textbook on clinical history taking, and to be assured that the history is the part of the clinical process which will deliver you the diagnosis. The ability to glean the diagnosis from the history is won by long experience (and even then is not infallible – you may be experienced in history taking, but the patient may not be experienced in history giving). At first you will not know what information matters and what does not: you will write too much, and you will show a keen interest in everything the patient tells you (which may win you points as a good listener), because you cannot separate the wheat from the chaff. Only slowly, as you come to know the many patterns of presentation which routinely come to your door, will you interpret the common cues from the patient’s tale.
The history taking conversation has an agenda. It is your job to pursue it. Establish a rapport with the patient quickly, and direct the conversation to elicit the information which you need.
Ask who the patient is, how the injury happened, what effects it is having and the medical history, especially any aspects which have a bearing on the present situation. Use open questions. Listen and observe. Once the broad outline is clear, there will be an indication of what the problem may be. Ask clarifying questions, inviting brief factual replies. This should help you to make a differential diagnosis, a list of the possible causes of the patient’s problem.
This is an ideal picture. It is only possible to direct the process skillfully if you have some idea where it is going. This takes knowledge and experience. Some patients can be so talkative, or so monosyllabic, that it is a struggle to get useful information out of them.
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