Training activity information
Details
Complete patient records for each stage of treatment when providing a patient with a facial prosthesis
Identify the relevance and implications for continuity in patient care, as a professional and your Trust
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?
- Success means meticulously completing patient records at every stage of facial prosthesis treatment, ensuring accuracy and completeness. It also requires you to articulate the relevance of these records for patient care continuity, your professional accountability, and the Trust’s operational integrity.
- Consider the learning outcomes focused on quality management systems, communication, and professional practice.
- Clarify specific documentation standards, expected level of detail, and the implications of incomplete records within the Trust.
What is your prior experience of this activity?
- What is your existing knowledge of patient record-keeping best practices, data protection, and the specific documentation requirements for medical device provision, particularly facial prostheses?
- What difficulties might arise in maintaining consistent, detailed records across multiple treatment stages, or in identifying all relevant implications for continuity of care, and how will you address them?
- When would you need to consult with legal/governance teams, data protection officers, or senior colleagues regarding documentation policies?
- How do you feel about the administrative yet critical aspect of thorough record-keeping and its broader impact?
What do you anticipate you will learn from the experience?
- Focus on improving your precision in record-keeping, your understanding of audit trails, or your ability to articulate the medico-legal implications of documentation.
- What insights do you hope to gain about how comprehensive records directly influence patient safety, inter-departmental communication, or regulatory compliance?
What additional considerations do you need to make?
- Review any feedback or identified areas for improvement from prior record-keeping tasks or audits.
- What specific details (e.g., materials used, patient feedback, complications, adjustments) must be consistently recorded at each stage of facial prosthesis provision?
In action
During the activity is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate during the documentation process? Are you encountering situations such as:
-
- You are finding unexpected gaps in existing patient records?
- The patient reveals new, critical information during treatment that needs immediate recording?
- You are encountering a challenge in documenting a specific, unusual stage of treatment?
- How does this experience compare with previous experiences of similar activities?
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you immediately adapting your record-keeping to capture new information? Are you identifying and addressing any perceived gaps or inconsistencies in real-time to maintain continuity? Is it affecting your ability to undertake the activity independently?
- Consider the steps you are taking in the moment, such as:
- Are you immediately consulting professional guidelines for clinical documentation, report writing templates, or specific departmental policies?
- Are you seeking advice from a more experienced colleague on how to phrase a difficult section or ensure completeness of historical documentation?
- Consider how you are feeling in the moment. For instance, are you finding it difficult to adapt? Is it affecting your confidence? Do you feel positive that you can reach a successful conclusion?
What is the conclusion or outcome?
- How are you working within your scope of practice?
- Are you successfully documenting the case by adhering strictly to local and national patient data privacy and confidentiality policies when you review and add information?
- Are you practicing within your scope by ensuring the documentation is sufficiently comprehensive to maintain professional accountability and guarantee continuity of care across all stages of treatment?
- Are you ensuring the records identify and record the psychosocial implications of the prosthesis fitting, confirming a holistic approach to patient care?
- What are you learning as a result of the unexpected development?
- Are you gaining critical insight into structuring long-term records to ensure that information captured at the assessment stage (e.g., prognosis, psychosocial history) remains relevant for subsequent fitting and follow-up stages?
- Are you learning a specific, efficient technique for documenting unusual or non-standard stages of treatment (e.g., implant failure, revision surgery) to maintain documentation rigor?
On action
What happened?
- Summarise the key points of the experience, focusing on completing patient records for each stage of treatment for a facial prosthesis, and considering their relevance for continuity of care, your professional role, and the Trust.
- Consider specific events, actions, or interactions that felt important. Did you find unexpected gaps in existing records or encounter challenges in documenting an unusual treatment stage?
- Include any ‘reflect-in-action’ moments where you adapted to the situation as it unfolded. For example, how did you immediately adapt your record-keeping if new critical information was revealed or if you needed to consult professional guidelines for clinical documentation in real-time?
How has this experience contributed to your developing practice?
- Identify what learning you can take from the experience. What strengths did you demonstrate in maintaining comprehensive and accurate patient records, ensuring professional accountability? What skills and/or knowledge gaps were evident (e.g., unfamiliarity with medico legal aspects or the clinical governance framework)?
- Compare this experience against previous engagement with similar activities. Has your practice improved in efficiency or accuracy in record-keeping for complex facial/body prostheses?
- Identify any challenges you experienced and how you reacted to these. Did these challenges affect your ability to undertake the activity independently, especially in maintaining a high standard of documentation?
- Identify anything significant about the activity. Did you need to seek advice or clarification on regulatory requirements or Trust policies?
- Acknowledge any changes in your own feelings now that you are looking back on the experience.
What will you take from the experience moving forward?
- Identify the actions / ‘next steps’ you will now take to support the assimilation of what you have learnt.
- What will you do differently next time? For example, routinely reviewing national and international standards and guidance for documentation or practising using templates for integrating multidisciplinary input.
- Do you need to practise any aspect of this activity further?
Beyond action
Have you revisited the experiences?
- Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity (completing facial prosthesis patient records)?
- When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to accuracy and conciseness, ensuring continuity of patient care, or documenting compliance with medico-legal aspects?
- 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 patient record keeping with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the legal, ethical, professional, and technical issues associated with medical device provision and the clinical governance framework?
How have these experiences impacted upon current practice?
- 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? For example, how does your improved adherence to documentation standards and regulatory requirements strengthen your ability to succeed in a Case-based Discussion (CBD) where you must justify your record-keeping protocols?
- How has your practice related to practicing in accordance with local and national health and safety policies and adhering to a quality management system developed and evolved over time across multiple instances of undertaking this training activity?
- Can you identify specific examples of improvement or increased confidence in capturing the psychosocial requirements of the patient accurately?
- Based on your experiences, how has your ability to recognise when something related to patient records is beyond your scope of practice improved?
- Do you have a clearer understanding of when and from whom (e.g., clinical governance lead, medical legal advisor) you need to seek advice or clarification regarding unusual ethical dilemmas in reporting or managing complex data interpretation for documentation?
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. |
| # 9 |
Outcome
Practice in partnership with other clinical specialisms as part of a multidisciplinary team and understand their roles and their impact on patient care and pathway. |
| # 10 |
Outcome
Apply the principals of a quality management system to their professional practice. |
| # 12 |
Outcome
Assess and interpret patients’ needs to provide customised treatment dependent on medical, physical, social and psychological requirements. |