AALVEZ’S MAR [15-03]:Written Communication

Indexing Title: AALVEZ’S MAR [15-03]
MAR Title: Written Communication
Date of Medical Observation: 2015
Tag: Making a prescription in a way a patient understand
Category: Professional/Ethical – Reinforcement


It was 4AM in the morning. A 39-year-old female came to me with a letter on her hand. She was an employee from another hospital and was accompanied by her husband. She was seeking urological consult due to her ultrasound findings of a stone in her ureter. I then proceeded to interview and examined her to further assess her condition.

I found out that she was having flank pain for 1 month. She was seeking consult to different doctors. She was actually confused from what was happening to her. I consulted with my senior resident regarding her case. We referred the case to the urology consultant. We were advised to have her for further diagnostics and medicines. I explained to the patient what plan we have for her and what medicines she would take. We then advised her to have a consult at the outpatient department once the diagnostics was done. We made laboratory request and prescriptions for her. I handed it over to them. They soon thanked us and made their way outside the emergency room.

A few minute has passed. The patient returned to me and asked me again about the prescription we made. She specifically asked on how to take the medicines we prescribed, what time would she take each one. I looked upon the prescription and explained to her thoroughly how to take each medicine we prescribed. After my explanation, she told me that she does not understand what we wrote in the prescription and she would appreciate if we would translate the prescription to Filipino.

Upon immediately knowing her concerns, I made another prescription in Filipino with the time needed for each medicine. I handed her over the new prescription. Immediately, the confused face was converted to a smiling one. She thanked me for the effort in doing the prescription and she promised to come back once the diagnostics has been done.

(Physical, Professional/Ethical, Psychosocial)
(Discovery, Stimulus, Reinforcement)

We encounter different kinds of patient throughout our tour of duty in the emergency room. Mostly we meet patients in need of immediate medical and surgical attention. Once the patient came in our doorsteps, we immediately assessed our patients and refer them to the proper channels to help alleviate their health concerns.

Communication is key in our patient interaction in our life as a surgeon. We discuss and explain thoroughly their condition and their choices regarding their disease. We establish rapport with our patient to gain their trust and consent in managing their health concerns.

However, communication with our patients does not end in how we converse to them. Our prescriptions, drawings and illustrations are as vital as our spoken or verbal communication to our patients. It is important to make our written notes or prescriptions not only comprehensible, but also understandable or readable in a language known to our patient. We could employ the use of illustration or symbols if needed to further instruct our patients on taking a medicine. Being able to communicate effectively with our patients is the most important of our relationship with our patient.

ROJoson’s Notes (17feb8):

Understandable communication and closed-loop communication are important in the management of patients.

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