Case reviews

This section of the impact toolkit provides suggestions for case reviews in the following musculoskeletal topic areas:

• Low back pain
• Investigations
• Referrals

Recording what happens in a consultation (or case study) demonstrates that an individual:

• uses best practice
• deals with problems appropriately
• responds to emergencies
• is keeping up to date with (and using) the latest guidance.

It also helps the individual provoke thought, reflection and action which may impact on future behaviour and improve clinical practice. Examples of this kind of activity might include reviewing an unusual presentation, a rare condition, a referral on instinct that turns out to be significant, or a wrong word that changed the consultation.

This learning by experience often goes unrecognised. However, by demonstrating the impact of this learning on patient care, it can be converted into CPD credits.

Consider reviewing 20 patients with a diagnosis of low back pain in the past year. Look at their management.

• Has the problem resolved?
• Did they have time off work?
• Was a 'fit note' issued? If so:
• Could their case have been managed differently to get them back to work sooner?
• What was the outcome of the certification?
• Has the patient returned to work?

Serology

Review 20 patients you have seen in the last year who have had rheumatology serology tests (e.g. rheumatoid factor, anti-CCP, HLA-B27, ANA/ANF).

Were these patients subsequently referred to see a rheumatologist?

• How much information did the tests add to the clinical picture?
• Did they affect your management of the patient?

X-rays

Consider performing a retrospective review of patients who have had x-rays for knee pain in the past year:

• Did your history and examination findings correlate with the x-ray report?
• Did the result of the x-ray alter your management?
• How will this change your approach in future?

Consider performing a retrospective review of patients who have had x-rays for back pain in the past year:

• Did your history and examination findings correlate with the x-ray report?
• Did the result of the x-ray alter your management?
• How will this change your approach in future?

Magnetic Resonance Imaging (MRI)

Consider performing a retrospective review of patients who have had MRI scans for knee injuries (Read code for MRI scan: 56N91):

• Did your history and examination findings correlate with the MRI report?
• How will this change your approach in future?
• How confident do you feel about diagnosing a meniscal injury or ligament injury without an MRI scan?

Consider performing a retrospective review of patients who have had MRI for back or neck pain in the past year (with or without radiculopathy):

• Did your history and examination findings correlate with the MRI report?
• How will this change your approach in future?
• How confident do you feel about diagnosing a prolapsed disc without an MRI scan?

Review the last 10 musculoskeletal referrals (e.g. rheumatology, orthopaedics, sports and exercise medicine):

• Did your provisional diagnosis and plan fit with the outcome of referral?
• Could any other appropriate management have been delivered in primary care or the community (e.g. physiotherapy, occupational therapy)?
• Suggested action:

1. Keep a note of your referrals, approach practice administrator or search Choose & Book for referrals.
2. Look through referral letter and letter from appointment.
3. Was the reason for the referral clear?
4. What was the outcome of the referral?
5. Could this patient have been managed more appropriately in primary care or the community?

Review a random selection of musculoskeletal referrals in the past year who were discharged after a single outpatient attendance:

• Was the referral appropriate?
• Could these patients have been managed differently?