Craniofacial and Trauma Rehabilitation —
Training activity: 12

Details

Under supervision record a comprehensive and contemporaneous history for a patient requiring prosthetic rehabilitation

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.

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?

• Identify what is expected of you in recording a comprehensive and contemporaneous patient history for prosthetic rehabilitation. Consider how the learning outcomes apply, such as delivering patient-centred care, effective communication, and analysing information.
• Discuss with your training officer or supervisor to gain clarity on specific criteria for thoroughness, relevance to prosthetic needs, and documentation.

What is your prior experience of this activity?

• Think about what you already know about taking patient histories, especially for patients requiring prosthetic rehabilitation.
• Consider possible challenges you might face, such as sensitive patient information or complex medical backgrounds, and think about how you might handle them.
• Recognise the scope of your own practice for patient history taking under supervision, and know when you will need to seek advice or help and from whom.
• Acknowledge how you feel about undertaking this patient interaction and documentation activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in patient interviewing, empathetic communication, or structured documentation, drawing upon previous patient interactions.
• Identify the specific insights you hope to gain about the unique needs and perspectives of patients undergoing prosthetic rehabilitation.

What additional considerations do you need to make?

• Consult actions identified following previous experience with patient interviews or documentation that could improve your approach.
• Identify important information you need to consider before engaging in this activity, such as the patient’s condition, the purpose of prosthetic rehabilitation, or ethical considerations.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate while recording the comprehensive and contemporaneous history?
• Are you encountering situations such as:
  • The patient having an unexpected emotional response or distress related to their deformity or trauma, shifting the focus of the session?
  • Difficulty obtaining clear or relevant historical information due to communication barriers or the patient struggling to recall critical details?
  • The patient revealing a significant, unanticipated non-audiological co-morbidity (e.g., severe mental health issue, complex relationship dynamic)?
  • The history strongly suggesting a need for immediate counselling or psychological support that goes beyond routine audiology-led counselling?
• How is this experience comparing to previous patient interactions?

How are you reacting to the unexpected development?

• How is this impacting your actions? Did you adapt or change your questioning or communication approach in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately using active listening and validation techniques to address emotional distress?
  • Adapting your questioning style to address unexpected psychosocial issues or complex medical history?
  • Are you seeking immediate advice from your supervisor regarding sensitive psychological issues or conflicting historical accounts?
  • Are you carefully redirecting the conversation to stay within your professional scope while maintaining the patient-centred principle?
• How are you feeling in this moment? Is the unexpected emotional response affecting your confidence in maintaining a comprehensive record?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice (e.g., demonstrating that you recognise the non-audiological co-morbidity and considered appropriate onward referral before you proceed with the prosthetic plan).
• What are you learning as a result of the unexpected development? For example, are you learning a more effective way to manage emotionally charged discussions or gaining proficiency in capturing a comprehensive and contemporaneous history under pressure?

On action

What happened?

• Begin by summarising the key points of the experience of recording the patient history, including the patient’s condition and the context of their prosthetic rehabilitation needs.
• Consider specific events, actions, or interactions which felt important, including your own feelings during the experience. E.g., Eliciting sensitive psychological history related to trauma or deformity; managing a patient who is withdrawn or excessively verbose; or ensuring all necessary consent and referral documentation is present before proceeding.
• Include any ‘reflect-in-action’ moments where you adapted to the situation, e.g., modifying your questioning approach based on patient cues, as it unfolded.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding recording comprehensive and contemporaneous histories. What strengths did you demonstrate in active listening, structured questioning, or empathetic communication? What skills and/or knowledge gaps were evident in eliciting comprehensive information or handling sensitive topics?
• Compare this experience against previous engagements with patient history taking. Were any previous identified actions for development achieved? Has your practice improved in recording comprehensive and contemporaneous histories?
• Identify any challenges you experienced e.g., patient difficulty in recalling information, language barriers, emotional responses, 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 the activity. Did you need to seek advice or clarification from your supervisor? Did you need to escalate any immediate concerns to ensure you were working within your scope of practice?
• Acknowledge any changes in your own feelings now that you are looking back on the experience.

What will you take from this experience moving forward?

• 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.
• What will you do differently next time you record a patient history? Has anything changed in terms of your approach to ensuring comprehensiveness and accuracy?
• Do you need to practise any aspect of this activity further, such as specific questioning techniques or rapport building? E.g., Practising specific questioning techniques (e.g., probing questions) to elicit functional and psychosocial information, or developing a structured rapport-building method for sensitive topics, or reviewing documentation standards for contemporaneous records.

Beyond action

Have you revisited the experiences?

• Review your previous reflections on taking patient histories for prosthetic rehabilitation. What specific actions did you identify to improve your history-taking skills, such as asking about physical, social, or psychological requirements? Have you implemented these actions, and are you ready to demonstrate improved ability?
• Share experiences of challenging patient history scenarios with peers. Has their feedback or similar stories broadened your perspective on communication and patient evaluation?

How have these experiences impacted upon current practice?

• How will your refined history-taking skills support you in observed assessments?
• How has your practice in effectively communicating with patients and assessing their needs for customised treatment developed over time?

Relevant learning outcomes

#	Outcome
# 1	Outcome Deliver quality patient centred care with the best interests of patients in all elements of practice.
# 2	Outcome Practice in accordance with local and national health and safety policies, regulatory requirements and overall service governance.
# 3	Outcome Communicate effectively with patients, relatives, healthcare professionals and other stakeholders.
# 4	Outcome Apply the principals of a quality management system to their professional practice.
# 6	Outcome Perform clinical investigations, formulate treatment plans and manufacture medical devices to a safe clinical standard.
# 7	Outcome Analyse and interpret patient investigations, multimodal imaging and information.
# 8	Outcome Select appropriate biomedical materials and components used in the treatment of patients and the manufacture of custom-made medical devices.