Doctors (and patients) also have access to up to date quality assured guidance on clinical diagnosis and management. It is helpful if both patient and doctor access them as dialogues for acute, continuing, preventative and health promotional relationships progress.
Angina is a good example:
We did a small study to see if patients could find the stages and processes of their expected care pathways in their notes for diabetes, thyroid replacement therapy, hypertension (raised blood pressure) and most managed to find 50% to 75% thus checking the completeness and quality of their care.
Here is an example primary care pathway which would be expected to be completed and recorded in a patients/you notes:
What information and support should I provide for a person with stable angina?
Provide information and support for people with newly diagnosed angina.
- Clearly explain the diagnosis of stable angina to the person. The explanation should include:
-- Factors that can provoke angina, such as exertion, emotional stress, exposure to cold, or eating a large meal.
-- The long-term course of angina.
-- Information on how angina is managed.
- Encourage the person to ask questions about their angina and its management.
- Explore and address any misconceptions the person might have about their angina. This includes:
-- Implications for daily activities.
-- Risk of myocardial infarction.
-- Life expectancy.
- Advise the person to seek medical help if there is a sudden worsening in the frequency or severity of their angina.
- Discuss the reasons for treatment, as well as the benefits and adverse effects (such as flushing, headache, and light-headedness). For more information, see the section on Prescribing information.
--Provide information on how to use a short-acting sublingual nitrate and when to administer it.
- Assess the person's need for lifestyle advice to manage their cardiovascular risk.
- Explore and address issues according to the person's needs, which may include:
-- Self-management skills such as pacing their activities and goal setting.
-- Concerns about the impact of stress, anxiety, or depression on angina.
-- Advice about physical exertion including sexual activity.
-- Advice about other activities such as driving, flying, and work.
- Advise people that the aim of anti-anginal drug treatment is to prevent episodes of angina and the aim of secondary prevention treatment is to prevent cardiovascular events such as heart attack and stroke.
HIFA profile: Richard Fitton is a retired family doctor - GP, British Medical Association. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data
Email address: richardpeterfitton7 AT gmail.com