Training activity information
Details
Write accurate and concise patient records and report for the assessment and management of adult patients
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Considerations
- Key findings and management plan
- Structure and language appropriate for the recipient
- Multidisciplinary team working
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What does success look like for writing accurate and concise patient records and reports for adults? e.g., What are the essential components of a comprehensive patient record and report? What standards (e.g., professional guidelines, clinic policy) govern documentation?
- What is your prior experience with writing clinical notes or reports? e.g., What elements do you usually include? What challenges have you faced in being both accurate and concise? What is your scope of practice regarding patient documentation? How do you feel about writing reports?
- What do you anticipate you will learn from this experience? e.g., What skills related to structuring reports, summarising complex information, or ensuring accuracy and conciseness do you want to develop? What insights do you hope to gain about the importance of good documentation?
- What additional considerations do you need to make? e.g., Have you reviewed examples of well-written adult reports? Are there specific templates or formatting requirements you need to follow?
In action
- Are you noticing anything surprising or different from what you anticipate during the process of writing accurate and concise patient records and reports for adult patients? Are you encountering situations such as:
- Difficulty summarising complex assessment findings and management decisions into a concise, yet comprehensive and clear report?
- Realising during documentation that critical information (e.g., patient’s primary concern, specific test parameters) was missed or inadequately captured during the assessment/management session?
- Conflicting information within the patient’s history or test results that is challenging to reconcile and present coherently in the report?
- Struggling to articulate the rationale for your management plan clearly and persuasively for other healthcare professionals?
- Unexpected requirements for specific reporting elements, formatting, or legal disclaimers that you weren’t immediately familiar with?
- How does this experience compare with previous experiences of similar activities?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to the procedure? Is it affecting your ability to undertake the activity independently? Consider the steps you are taking in the moment, such as:
- Are you immediately re-checking original data, consulting previous notes, or cross-referencing information to clarify details?
- Are you consulting professional guidelines for clinical documentation, report writing templates, or specific departmental policies?
- Are you seeking advice from a more experienced colleague or your training officer on how to phrase a difficult section, manage conflicting data, or ensure completeness?
- Are you changing your initial approach to report organisation or verbosity based on the complexity of the case or feedback on previous reports?
- How is any unexpected development being resolved as you progress during the activity? How are you working within your scope of practice? Are you successfully managing the situation yourself, or do you need support because it is beyond your current scope (for example, if a report has legal implications or requires a specific consultant’s detailed input)?
- What are you learning in this moment as a result of any unexpected development? For example, are you learning more effective ways to structure reports for clarity and impact, or to identify and address information gaps proactively during the clinical encounter?
On action
- Begin by summarising the key points of how you wrote the patient record and report for an adult patient’s assessment and management. Describe what information was included and how it was structured.
- Consider specific events or actions that felt important, such as ensuring accuracy of test results, clearly articulating findings and impressions, or summarising complex management plans concisely. How did you feel during the documentation process?
- Include any ‘reflect-in-action’ moments, where you had to adjust your writing style, content, or emphasis based on a review of the patient’s case or a new insight gained during the writing process.
- Identify what learning you can take from this experience regarding writing accurate and concise patient records and reports.
- What strengths did you demonstrate (e.g., attention to detail, clarity, adherence to standards, logical flow)?
- What skills and/or knowledge gaps were evident (e.g., efficient use of clinical language, structuring complex information, ensuring all necessary components are included consistently)?
- Compare this experience against previous engagements with similar activities. Were any previously identified actions for development achieved (e.g., faster writing, more comprehensive yet concise reports, better integration of multidisciplinary input)? Has your documentation practice improved?
- Identify any challenges you experienced (e.g., summarising a complex case concisely, ensuring all relevant details are captured without redundancy, time constraints) and how you reacted to these. Did this affect your ability to deal with the situation? Were you able to overcome the challenges?
- Identify anything significant about this activity, such as needing to seek advice or clarification on documentation standards or specific phrasing, or if you had to amend a report significantly after initial drafting.
- Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learned, including from any feedback you received on your documentation.
- What will you do differently next time you write patient records and reports for adult patients?
- Has anything changed in terms of what you would do if you were faced with a similar situation again?
- Do you need to practise any specific aspect of documentation (e.g., using templates, improving conciseness, integrating multidisciplinary input) further?
Beyond action
- Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity (writing adult patient records and reports)?
- When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to structuring reports, concisely summarising findings, using appropriate clinical language, ensuring accuracy, or maintaining confidentiality?
- Have you completed these previously identified actions? If not, what are the barriers? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when performing this task?
- Have you engaged in professional storytelling or discussed your experiences of adult patient documentation with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the legal implications of record-keeping, the importance of clear communication for multidisciplinary teams, or efficient documentation workflows?
- Considering your cumulative experiences and reflections on this activity, how will the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module?
- How has your practice related to writing adult patient records and reports developed and evolved over time across multiple instances of undertaking this training activity?
- Can you identify specific examples of improvement or increased confidence in efficiently producing comprehensive reports, tailoring reports for different audiences (e.g., GP vs. ENT), or using electronic health record systems effectively?
- Based on your experiences, how has your ability to recognise when something related to adult patient documentation is beyond your scope of practice improved?
- Do you have a clearer understanding of when and from whom (e.g., supervisor, clinical governance lead, medical legal advisor) you need to seek advice or clarification regarding unusual ethical dilemmas in reporting, complex data interpretation for documentation, or discrepancies in patient information?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 4 |
Outcome
Assess and manage hearing function in adults, without co-morbidities. |