Academic Day Seminar #4: Clinical Thought Process

For this ADS, Tila Pelletier went over the patient-work up, data-collection, data synthesis, and clinical thought process. I thought this was a very useful session to have, especially before starting my clinical orientation.

Some Key Points I took away from this session are:

  • Your clinical process is a systematic approach to a patient. It is the process by which you collect, interpret and apply information regarding your patient’s care pain. It is something you must continually work to improve. It must be consistent and complete!

Prior to this session, I mainly thought of clinical thought process as a process to synthesize and apply information. It was something that I would attempt to do after gathering all the needed information. As Tila mentioned later on in her session: Think about your care plan as you gather information. Don’t be in ‘gathering mode’ but in ‘thinking mode'”. For my future patient work ups, I need to be critical at every step. I think using the head-to-toe approach taught by Dr. Kanji taught us when collecting information (e.g. patient-interview) and interpreting information would help me be more systematic when applying the information to the patient. If I am struggling at a certain step, I need to ask myself if I have all the information I need to make an effective and safe plan, and assess my current knowledge on the topic (e.g. pathophysiology, therapeutic options, diagnostics, monitoring plan, current updated literature).

My current goal is to continuously build and develop my clinical process and ensure that it is consistent and complete. As I progress through residency, I will need to push myself to be more efficient with my process while keeping in mind that efficiency should not sacrifice thoroughness.

  • You must check at least these 6 places for information:
    1. Computer system (e.g. drug profile, transcriptions, labs, imaging reports, etc)
    2. Patient Chart (physician notes, nurse notes, MARs, MD orders, etc.)
    3. Vital sign documentations
    4. Current day’s MAR, glucometer readings, bowel movements, urine output, fluid status.
    5. Care connect full 14 month pharmanet (Medinet) and outpt laboratory data (eHealth Viewer)
    – see trends in labs and identify if it is a chronic or acute issue
    6. Patient interview!!! Best possible medication history
    – Interview patient on meds that were d/c in the past and reasons behind it
    ** Other souces of info: Patient’s family, Community Pharmacy, GP/other HCPs, Previous admissions, Nurses on the ward, Assisted Living Facility, HOme Cardiologist, PARIS (out pt social worker documentation which social worker has access to), Transfer charts (by fax) **

Generally, when I look for information, I generally look for it in the above order. During my clinical orientation, my preceptor told me he likes working from the back to the front when reading the patient chart. As I had more experience reading patient charts, I could see the importance of understanding the patient’s history in their current admission (e.g. understanding the med changes and why it occurred, current status of patient’s c/c). I think that I am fairly decent in collecting information in the 1st 3 areas, but need to work on #3-6 and to have a list of things I should be looking for in each patient I encounter (e.g. IV fluids (input and output), bowel movements, frequency of PRN meds).

  • “The drug and the dose are wrong until proven otherwise” AND in the systhesis, always ask:
    • Does every drug have an indication?
    • Does every indication have (the right) drug(s)?:

When I work up my patient, I need to question each drug and whether the drug, dose, duration, route, formulation is necessary, most effective and safest option for the individual patient.For elderly patients, I also need to keep pill burden in mind. Tila also mentioned the importance of knowing if you are dosing to effect or dosing to target. This is something I will have to build my knowledge on.

  • Keep a list of things to look up/read about as you are going through the report with your preceptor. Keep this list on a separate piece of paper. Check in with your preeptor every 1-2 days to make sure you review what you have looked up. Self-reflect each week.

This is definitely something I will have to improve on. During my hospital OEE rotation, I would keep notes on what to look up. However, I was very disorganized and by the end of the day, I had to sift through scribbles on different pieces of paper to ensure I had researched everything I needed to. I think I will try Tila’s advice to use a coloured piece of paper to record my list of things to read. In order to improve on my thought process, I will check in with my preceptor every few days for feedback on my thought process and self-reflect when I have missed something in my thought process and decide a course of action (e.g. modifying my monitoring form, changing my organization methods).