OSCE DOCUMENTATION AND PRESCRIBING

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Welcome to Teaching Things!

We're excited to bring you this high-yield teaching series, designed to help you ace both your written and practical exams.

This tutorial will focus on OSCE DOCUMENTATION covering key topics of DOCUMENTATION and PRESCRIBING to ensure you're well-prepared.

The session will be led by ANIRUDH MANIVANNAN and HARISH BAVA, both medical students in their clinical years at UCL, who are passionate about delivering practical, exam-focused content.

Don’t forget to fill out the feedback form after the tutorial—we value your input! And remember, you can access recordings of all past tutorials on our page.

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ALL YOU NEED TO KNOW ABOUT OSCE Prescribing and Documentation Reviewed byivannan and Harish Bava Here’s what we do: ■ Weekly tutorials open to all! 18:00 every Thursday ■ Focussed on core presentations and If you’re new here… teaching diagnostic technique from a clinical perspective ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats! OSCE Documentation Anirudh ManivannanBefore we begin, how conﬁdent are you on documentation ? What we’ll be covering 1. Documenting a ward round (SOAP) 2. Documenting a procedure 3. Documenting a CXR 4. Referral letter Documenting a ward round - What is the best structure to document a ward round? - There are many but SOAP is a commonly used method! - S - Subjective - O - Objective - A - Assessment - P - Plan What to include in each section Inpatient Outpatient Subjective (What patient says) How patient has been since last review, PC, HPC, Systems Review, PMHx explore any symptoms Objective (Anything measured) - Patient appearance - Patient appearance - Obs - Obs - Fluid balance - Physical examination - Physical Examination - Test results Assessment (What’s going on?) - Summary - Summary of clinical problem - Diagnosis/Problem List - Differentials/diagnosis Plan Investigation Investigations, Management plans, Management: Escalate to seniors, Safety netting Managing the patient, Monitoring the Pt, Preventative measures, Surgery (NBM) Susan Smith Example 11/01/1939 12345 12/06/2025 Anirudh Manivannan, Respiratory Ward Round 6:00pm S - Worsening SOB, Pyrexia in last 3 days, Generalised Body Pain O - Hb 100, Plt 250, WCC 22, CRP 30, Urea 23, WCC, CRP A - Bloods keeping with CAP P - 1. Calculate CURB-65 2. Start Abx 3. Oxygen 4. IV Fluids 5. Senior Review Signed Anirudh Manivannan 4th year medical student 1234 Documenting an ABG 1. Indication 2. Interpretation 3. Impression 4. PlanDocumenting an ABG xDocumenting catheterising procedure What should you include? - 1. Size of catheter, - 2. Residual volume, - 3. Colour of urine, - 4. Difficulties on insertion, - 5. Volume in balloon, - 6. Any prophylactic antibiotic givenHow to document a CXRDocument this CXR Example Name ~ Macauley Cooper Date of birth ~ 23/05/1940 Hospital number ~ Y154575 Date and time ~ 26/08/22, current time or some time after 13:40 Documentation of chest X-ray Date and time CXR performed ~ 26/08/22 at 13:40 Indication for CXR - SOB, fever, productive cough OR pneumonia Documents image quality ~ some rotation; 7/8 anterior ribs noted so good inspiration; PA film Documents airway findings ~ trachea central; carina and bronchi normal (although slightly obscured by necklace); no obvious hilar abnormalities Documents breathing findings ~ area of increased opacity in the left lower zone; no pleural abnormalities; no areas lacking lung markings Documents cardiac findings ~ cardiac borders visible, normal heart size; normal cardiophrenic angle Documents diaphragm findings ~ mild blunting of left costophrenic angle Documents other findings ~ normal mediastinal contours; no bony abnormalities; no tubes/valves/devices; necklace/medic alert chain worn Impression and plan Impression ~ community acquired pneumonia Documents appropriate plan ~ e.g. maintain oxygen saturations 94-98%, sputum cultures, blood cultures, bloods (FBC, U&Es, LFTs, CRP), antibiotic therapy (depending on local guidelines, but for example co-amoxiclav 625mg PO TDS for 5 days)Referral Letter What to include? - Patient details - History, summary and examination ﬁndings - Suspected diagnosis - Why they need to be seen - Often SBAR can make a good structure not only for telephone referrals but also referral lettersExample OSCE Prescribing Harish BavaWhat will we be covering? ■ General patient details ■ Allergies ■ Prescribing post-surgery - maintenance ﬂuids, pain relief, thromboprophylaxis ■ Prescribing for an acute asthma attack ■ Prescribing for an acute coronary syndrome ■ Prescribing for infectionsGeneral Patient Details The important ones to always have: ■ Full name ■ DOB ■ Hospital number ■ Gender ■ Weight ■ Ward ■ Date of admission ■ Date of documentationGeneral rules of prescribing You must always write: ■ Full drug name - brand names typically should not be used ■ Dose – Micrograms should never be written as mcg ■ Route – IV, Oral, Subcutaneous (SC), IM ■ Frequency – Always best to write out fully – Can write OD, BD, TDS, QDS ■ Signature, bleep number ■ Additional information – Why is the drug given, max number of doses, duration of course (if applicable), any monitoring required ■ If there is a set duration (e.g. 5 days), write dates and times on right side, and cross out the days after course is completeAllergies MOST IMPORTANT THING TO WRITE ON A DRUG CHART!! You need to write the drug name, and importantly what thereaction is! If no allergies, you MUST sign to say soScenario 1 You are on the post-op ward. You are asked to prescribe appropriate medications for a 72 year-old man who has just had a total hip replacement. He is NBM, has no known allergies, and complains of severe pain. What do you want to prescribe?Scenario 1 ■ Maintenance ﬂuids - how do you calculate this? ■ Pain relief - Morphine with a breakthrough dose PRN ■ Laxative – Opiods can cause constipation ■ Thromboprophylaxis – Should be given to anyone who is in hospital for >24 hoursMaintenance Fluids in adults Adults require: ■ 25-30 ml/kg per day of ﬂuid ■ 1 mmol of Sodium, Potassium and Chloride ions per kg ■ 50-100g glucose per 24 hours Remember: 2 sweet 1 saltyMaintenance Fluids in adults For example, adult of 80kg needs: ■ 2000-2400 ml of ﬂuid ■ 50-100g of glucose ■ Use 5% dextrose (1000ml contains 50g of glucose) ■ 80 mmol of sodium, potassium and chloride ions ■ Sodium and chloride given together as normal saline ■ Potassium is given using potassium chloride, added into the infusion – KCl is only available in 20 or 40 ml bags ■ Always give less potassium than more to prevent hyperkalemia – Should be spread out throughout the whole day to preventhyperkalemiaMaintenance Fluids in adults What infusions should be given? ■ 80 mmol of sodium and chloride – Given using 0.9% sodium chloride – Typically 500ml or 1000ml is given – Do not need to worry about these electrolytes too much - can give more or less ■ 5% dextrose ■ KCl Typically one infusion of 1000ml and one infusion of 500ml – Added into each infusion – Always round down to smaller amount To calculate duration of each infusion: - Volume of infusion/total ﬂuid volume x 24Scenario 1 ■ Pain relief – IM morphine - 5mg ■ Laxative – Docusate Sodium – Per rectum - 120mg ■ Thromboprophylaxis – Tinzaparin - 3500 units subcutaneous OD – OR enoxaparin 40mg subcutaneous OD – Always given at 1800pm40mgScenario 2 A 19 year old patient has presented with a severe acute asthma attack. What do you want to prescribe?Scenario 2 ■ BURST therapy – Back-to-back salbutamol and ipratropium bromide nebulisers ■ 20 minutes apart ■ Oral prednisolone – Stat dose – Prescribe the remaining 4 days in the main prescriptionsScenario 3 You see a 67 year old patient in the emergency department who has presented with crushing chest pain radiating to the jaw and down the left arm with associated nausea. Based on the ECG below, prescribe theinitial management. RR 25 BP 115/70 O2 97% HR 80Scenario 3 You want to prescribe STAT: ■ MONA: – Morphine - for pain relief – Oxygen - not required as not hypoxic – GTN sublingual spray – Aspirin 300mg ■ Antiemetic – Cyclizine 50mgScenario 4 You are in the GP Surgery. A 68 year old woman comes in with a 2 day history of coughing up sputum and feeling very breathless. She has no PMH. Her AMTS is want to prescribe?7/87 O2 89%. What is her CURB-65 score, and what do youScenario 4 CURB-65 score = 2 ■ >65 = 1 ■ RR > 30 = 1 You want to prescribe: ■ Oxygen - hypoxic ■ Antibiotics – Amoxicillin + Clarithromycin What else would you want to do?Stopping medications To stop a medication you must: ■ Put a clear line through the prescription ■ Sign with your name, signature, bleep ■ Date and time ■ Reason for stoppingAny questions? Thank you for listening Harish Bava Anirudh Manivannan Remember to ﬁll in feedback to get your certiﬁcate!