FY1 Survival Tips 2023: Ward rounds and Documentation



This on-demand teaching session for medical professionals covers essential topics relevant to ward round documentation, looking at the importance of good documentation, how to document during senior and solo ward rounds, and creating a jobs list. Doctor Hamza Tefali will explain the basics of good documentation, providing real examples of how to document during ward rounds, and why it is important in enabling continuity of patient care, and in writing discharge summaries. He will show how to document in detail, including patient observations and examination findings, and how to provide a plan for future care. At the end of the teaching session, Doctor Hamza Tefali will be available to answer questions.
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Huge congratulations on passing medical school and becoming doctors! Mind The Bleep is here to help ease your transition into your FY1 year.

Documentation is a vital part of your job and so it is essential that you gather the skills to write clear, concise and accurate information. To help you with this, Dr Hamza will be giving you tips on how to best document your ward round notes, discharge letters etc.

Please register to attend this session!

Learning objectives

Learning Objectives: 1. Understand the importance of good documentation and its legal implications. 2. Review good documentation practices, including tips for writing legible and courteous patient notes. 3. Recognize the role of documentation in promoting patient continuity, care and discharge summary writing. 4. Demonstrate knowledge of documentation during a senior-led ward round, including patient observation, examination findings, and plans for treatment. 5. Describe the importance of having a patient list or job list when documenting during a senior-led ward round.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

All right. Hello everyone. My name is Doctor Hamza to Fodor. Uh I'm a foundation year to doctor currently working in the West Midlands. And the topic of our lecture today is Ward runs and documentation. Throughout this topic, we will cover the importance of good documentation, how to document during a senior lead ward round, how to document uh during a solo ward round and a jobs list. So, uh if you have any questions, feel free to put them in the chat box, unfortunately, I won't be able to see the chat box at the moment. But after the lecture, I would be happy to answer any questions you do have. So what's the purpose of good documentation, documentation of patient notes is a legal document. So that's why it's important to write allegedly. Uh and it should not leave the hospital. So it's a legal document where anything that's written in, it can be used to look back when doing uh for instance, uh internal investigations into patient's death or just evaluating patient patient's care or doing some audit. It's also important to document well, to ensure good patient continuity. So good uh good patient care for instance, if you're the doctor seeing a patient on one of the days and on the following that you're not here, your colleagues will know the plan and what has been done through good documentation. Good documentation also allows for a good patient care within the multidiscipline disciplinary team. For instances, the nursing staff know what the plans are for a patient or the physiotherapist and occupational therapy are aware of the patient's uh plan expected discharge date. And that can help in facilitating a patient's discharge. Good documentation is also important in writing discharge summaries. For instance, if you're the doctor asked to write the discharge summary whilst you're on call for a patient, you don't know about, you can look through the patient notes and it's through good documentation that you, you get to know about the patient and the treatment they have received in hospital. And this will help you write a good discharge summary. And another reason for documenting well is that you can update patient and family members of a patient's care. So then when looking back, you know what's been done for the for this patient uh and the plan going forward, remember if you don't write it, it never happened. That's why it's always important to document every little thing you do. So here are the basics of good documentation. First and foremost, it's important to put the date and time and have the patient identifiable details. Uh Most hospitals using paper notes will have patient stickers with the NHS number and date of birth. For those of you working in hospitals with electronic patient records, the date and time and the patient identifiable details will already be there when documenting. It's important at the top to put your name and your role as well. Along with any other person who you were with, who have seen this patient. It's also important to include a plan of what you were thinking and how the treatment should go forward and on finishing your documentation, you should finish it by writing your name, your G M C number and uh signing, signing it as well. Good documentation should be legible. So think of the other colleagues, how will they understand something uh and understand the patient's care if it's not legible. And it's important to be polite in documenting and courteous as well because for instance, some patient's might be able to request their patient notes in the future. So here are two examples of documentation which I have done uh therefore fictitious patient's. But just to give you a broad understanding of how to document as a foundation, you're one doctor on the left hand side, you have the date and the time that's important to know at what time you saw this patient. And on top here you have the patient identifiable details or as I said in some hospitals, you can have a sticker which can replace that on the top. I have my name and my role as well. And that could be your role as an F Y one or it could also be as your role as an on call doctor, for instance, I was on call. So this just goes to show that I don't usually look after this patient on my normal day to day job and I'm just covering out of hours. And for this instances, I've been asked to review the position of the N G tube uh as confirmed by a chest X ray. So as you can imagine, it's really important that I document this because nurses would not want to start N G feeding unless it has been documented that the N G tube is in place. And I've also redid a plan uh with my documentation as well on finishing my documentation, I have signed it with my name and my D M C number as well. Most of you will get a stamp on starting as a foundation, your doctor, which will come in quite handy when documenting on the right hand side is another example of documentation where I have been asked to see a patient who has had a head injury. So again, I have the uh the date and the time on the left hand side, my role and my name along with the reason why I've been asked to see this patient. So this gives my colleagues an understanding of why I'm documenting in this patient's notes and why I'm reviewing this patient. And I in here, I have written the results of any investigations which I have done or which I have found and again, written a plan and signed it with my name G M C number and signature. So now I'll go on uh to touch on briefly of how to document during a senior lead ward run. So the majority of your ward ones you will do as a foundation year one doctor or senior lead. So that's either with a consultant or registrar. When you're documenting for a senior lead ward run. It's important you have a patient list or jobs list next to you that can come in quite handy. So you can write jobs along the way and you can refer to later after the ward run again at the top, you should write the date and the time along with the name and the role of the senior colleague who's leading the ward round. You can also write your name and your role next to that. It's important to prepare observations for the state for the patient, including their new score and any blood tests and the results and the trend of the blood tests as well. It can be quite relevant to include medications, patient's on. For instance, if a patient is being treated for sepsis and writing which type of antibiotic they're on and which day of the course of the antibiotic, uh they're currently on and any results of scans or procedures. This will give any doctor or any healthcare professional a general understanding of the patient when they read your documentation. So it provides a good summary as well. When you're going to see the patient by the bedside, you can write any observations you see of how the patient is doing. For instance, some colleagues may right. Patient is comfortable address if they are or they might choose to write patient short of breath or any signs or symptoms. The patient complains about. It's also important to write any relevant examination findings during the war drowned as this can give an indication of any diagnosis and to have a plan as uh as instructed by the senior person leading the ward round. So you can refer to uh for the future when doing jobs for this patient. So again, I've provided examples of documenting for a senior lead ward run. So that's just my style of documenting as start when starting as a foundation year one doctor. Uh you will each develop your own style of documenting, but here's just a general style to go about. Again, you have the date and the time on the left hand side, the patient details on the right, including their name and the NHS number or the hospital number. On the top. I've written the name of the senior uh person leading this ward run in this instance. It's a consultant just to reiterate that all the details in this are fictitious is and they're only being done to provide an example. On the left hand side, I like to write the patient's observations, including their new score and for what their score NG. And on the on the right hand side, I I also like to write uh the patient's blood tests and the trend of the blood test. So while when checking the trend of the blood test, you can see for instance, if the inflammatory markers are increasing or decreasing. So this for instances, the results of the blood test done on the fifth of June and on the right hand side, although I've not written the date or the blood test of the previous results. So you can see the White Cell Council is falling along with the neutrophil count on the top. I've given a brief history of this patient, a brief summary. For instance, this is a 60 year old mayor with a background of heart failure, type two diabetes and osteoarthritis. You, you might notice that I'm using a lot of abbreviations. That's because whilst documenting during award round time is limited and you're become familiar with common abbreviations you can use. I've written head of the 60 year old gentleman presented with a two week history of worsening shortness of breath and ankle swelling. And this little triangle symbol is commonly used amongst doctors, which means the diagnosis with this patient. So CCF is congestive cardiac failure. They also have a uti a urinary tract infection and an A K I stage one which which has been resolved. Below. I have gone on uh to document the treatment this patient is currently receiving. For instance, this patient with heart failure is currently being off loaded with IV furosemide twice daily and they're on a day free of a seven day course of trauma to print for their urinary tract infection. I've also included the results of any relevant investigations. For instance, the chest X ray is clear and an echocardiography has showed a left ventricular ejection fraction of less than 40% as I mentioned earlier. Uh these are the bids we prepare before going to see the patient. And by the bedside, you can record any observations you have seen. For instance, the patient was comfortable at rest and they had no new concerns to report. When asked when documenting examination findings, you can also make little drawings. For instance, you can draw two triangles to represent the chest and the lung fields, heart sounds are usually documented as one plus two. And if you do hear any additional heart sounds, you would document them on there. The abdomen sign is usually documented with this little uh symbol here. And if you do cross it out, it means that there are no relevant findings and that it's normal. And here I've just drawn to legs uh to show evidence of pitting edema to continue on on my documentation. Uh I've written a plan for this patient. So there to continue offloading, there to have their weight's taken daily and to have blood tests taken every other day and to continue on the antibiotics for the urinary tract infection. I've also written a plan uh If that, if this patient has a ferpa spike in temperature, blood cultures need to be taken. And the the case needs to be discussed with microbiology and other plan for this patient is to get the notes from another hospital and to start discharge planning for this patient. As you can see, this is a very comprehensive plan. And if my colleague who is not here, when we saw this patient on that day, comes in the next day and is to take over the uh patient's care. They can have a good idea of what we're planning for this patient as you can see from the temperature spike as well. If any other doctors on goal, uh they can follow the plan uh of what to do if the patient has a temperature spike. So that's why it's important to document well to ensure could continue to have patient care. And so your colleagues can continue on from the treatment you've given off for this patient, I'll briefly touch on uh some common abbreviations you might see as a doctor. Uh just a side note, these are only a few examples and you may come across more whilst working as a junior doctor and Able X is usually used for antibiotics. And, uh, this concept of time took me some time to come through it. So usually if you're writing one out of seven, it's because there's seven days in a week. So one out of seven means, uh, one day, one out of 52 because they're 52 weeks in a, in a year, one out of 52 means one week and one out of 12 because there are 12 months in a year means one month. BMS are commonly used to indicate blood sugar levels. N B M means near by mouth. Hr is heart rate or is respiratory rate. M F F D is medically fit for discharge. So that means uh this patient has completed all the medical treatment and usually, and, and they can go home, usually pending arrangement of facilities at home or package of care. PT and OT of physiotherapy and occupational therapy. Talk means trial without catheter. That means removal of the capital and seeing if the patient passes urine F U is follow up or slash B is review and P O C is package of there. So package of care is usually when a patient uh is fit to be discharged from hospital uh and they just need to be discharged into the community with additional support in place. And usually if you see a question mark, it means uh query of a suspected diagnosis. The next part is documenting for a solo lead ward round. That, that means when you're about to see a patient on, on your own. Although the instances of this happening might be few near the end of your uh found fy one post, you would be expected to see patient's on your own. Uh Sometimes, although don't worry, the uh the senior people who have seen this patient before will usually have a good comprehensive plan in place to follow. So it's important before documenting for solo uh war drug to prepare well and no, your patient well, familiarize yourself with the previous plan and the current management. So these are usually the plan made by senior consultants or registrars who have seen this patient the day before and follow their current management plan. As I mentioned earlier, it's important to check the patient's observation, including the new score. For most of you, the new score will be available on the computers. But for some of you, it might be available on paper notes and to check the blood test and the trend of the blood test which could point you towards a diagnosis when document when doing a solo lead ward round. It's important to update the patient of their blood test, their scan results and where their treatment is and they expected discharge date. If you're not sure of this. Uh you can always consult with the seniors and back to the patient. It's quite uh important to keep the patient in the loop of that treatment. When doing a solo lead ward run, it's also important to examine the patient systemic systematically to check for the improve improvement of symptoms and just to screen for any evidence of uh new infection which might have been missed before, always uh discuss the results with a senior that might be a registrar or consultant and have a low threshold to escalate. So if you're worried about the patient always escalate to senior member of staff, remember there's always support available around and you're never on your own. The next part of this lecture, we'll briefly touch on the creation of a jobs list. The jobs list is one of the most important things you can create every day as a junior doctor because it's go to piece of document where you can use to uh do jobs throughout the day, you might have the patient details, including their location. So for instance, the bay the patient is in their name and a quick diagnosis just to remind yourself of what this patient is being treated for any ongoing issues. And next to it, you can write any jobs that you need to do for this patient throughout the day. For instance, if you need to contact microbiology, do blood test for this patient update their family, right? A discharge summary or any blood test or any uh job you can think about. It's important to write it on your jobs list. So you don't forget. And usually it's important to write it on your jobs list as you go around during the ward round seeing the patient regroup after the ward run and go through the jobs list with your other colleagues to check that you have not missed on any jobs and go back to the notes if necessary to check uh that the plan correlates with the jobs list and then divide the jobs between yourself as junior doctors uh to complete the jobs by the end of the day. If there are any outstanding jobs uh that are important, you can always hand over to the on call doctor or to the night doctor. For instance, if you're about to finish your shift and if there's any jobs that are not important and haven't been done, uh you can always re refer to it on the following day and try to do these jobs if you have time on the following day. That's a, this is a common symbol used by junior doctors when creating the jobs. Like for instance, you can draw a little triangle and if the triangle is not shaded in, it means that the job is outstanding. So it still needs to be done. If you draw one line through the job, it means part of it has been done. For instance, if you have requested an X ray scan, but it has not happened yet, you can draw a stripe through line through it. When you shave off of the triangle, it means half of the job has been done. For instance, if the job is to take blood for a patient, you can shade half of it. If you've taken the bloods that are waiting for the results and you can completely, you can shade this rectangle completely. If you've completed the job to summarize this lecture, I've gone on to explain the importance of good documentation, how to document during solo and senior lead ward rounds and how to write ward round entries. I've also briefly touched on the importance of a jobs list. Thank you for listening to my presentation. I would be grateful if you could please feed, fill out the feedback form by stunning this QR code and feel free to put in any questions in the chat box, which I'll go on to answer shortly. Thank you. Okay. So I'll be happy to take any questions you guys have. Uh If you just put them in the chat box. Uh So Andrew has asked to trust that are completely electronic, have their own version for symbols or drawings. Uh No, unfortunately, those that have electronic notes won't have symbols. Uh So you'll just need to type them along. Is it common to have a jobs list on the ward computer that all doctors keep updated for the purpose of handover? Uh So in my experience, jobs lists are not on the computer, it's something that you need to write down by hand even in those trust where everything is electronic because your jobs list is for you. It's a personal jobs list. Uh and don't forget to dispose of your jobs list at the end of the day because it can contain confidential information. So dispose of it by throwing it in the confidential waste bin. Okay. I'll put the link for the feedback form just uh uh this lecture is also being recorded and will be available to watch on uh minor blips youtube channel as well. Uh So, Hasan has asked what you mean by putting off jobs for the next day. Uh So sometimes you'll have loads of jobs for a patient and they might not be enough junior doctors on the ward. So in that instance, if there are less urgent jobs to do, you can schedule them for the next day. Uh Common examples, I can think of uh preparing a discharge summary. So if you know the patient is not going home today, uh but you're anticipating, they might go home later on that week and you need to prepare the discharge summary and you're busy on that day. You don't need to do it immediately. You can do it whenever you have time. Do you guys have any more questions? Just to briefly share with you an important resource for incoming foundation year one doctor's. Uh at mindedly, we've created a survival guide booklet which you can find online. I'm just gonna share it now so you guys can have a quick look of what it looks like. So this is the Fy One Survival guide, which has been created by mindedly, it's being created by a team of doctors, including myself. And it has important information about uh things you might need as a foundation year one doctor. For instance, it covers the role of the multidisciplinary team, your role as an F Y One. Uh We have links to other resources, find the plea how to document as well. They're further examples in there of how to document a medication tips, common medications, you will be expected to prescribe as a foundation year one doctor. Uh the priority of the job, how to prioritize jobs. So jobs which are more important to do and those are that are less important to do writing discharge letters. An example of a discharge summary, we also have information about common resources that are useful for a foundation. You're one doctor uh apps you can download on your phone, joining the B M A N D M M D U and important information about you pay slip for instants, uh your gross pay tax, uh taking out student loans, keeping a credit score and a breakdown of different leaves you can take including annual leave, study, leave sick days and other relevant information. So uh to access to this, you can google the mind the bleep website and check, check out for the fy one survival guide booklet. So I'm just going to answer a few more questions we've had that have come up when you're making notes for a new patient on the ward using the ET report. I'm not quite sure the question Richard. Uh when you show the notes for senior Lead Ward run, was that what you wrote down the patient records or is it something personal for yourself? So to answer the question about the example I showed for a senior lead ward run, that's an example of something I've written for the patient's notes. Usually you won't be, you won't actually have time to document uh personal notes for yourself in that much detail. But when you're writing in the patient's notes, it's important to include as much detail as you can. And and that was just a good example of documentation during award run. Uh As you guys will be starting and rotating for different specialties of foundation training, you'll see that your style of documentation will change. For instance, whilst working in surgery, you'll have less time to document uh in that much detail. So you documentation will be very brief, but it's always important to remember to document the important things if you do procedures, example examples as Cannula does not need to be documented to uh so that depends on the person for instants, I usually don't document if I've done a Cannula, but I know of colleagues who do document it will also depend on your trust protocol. For instance, my uh some just is that you include the cannula stickers and the date and time of insertion of the cannula. So the nurses can check the hip score and to remove the cannula after it has expired. But in general, little things that you don't need to document include uh prescribing simple analgesia for patient such as paracetamol inserting cannulas doing bloods. You don't need to document those things that you do need to document include any discussion with any other specialties such as microbiology or radiology, uh any results or doing any procedures such as blood cultures or insertion of a catheter because this will allow you to know when those procedures who were done. And for instance, a catheter, you can then no the indication for insertion of the calf to and when the catheter needs to be removed. So how Marie has asked how to access the Survival guide? So if you join on the Minder Bleed page, I'll just see if I can find the link for it. This type in mindedly fy one survival guide. Uh There's a link on there and you need to register with your email address. So registering with your sign up for mind the bleep, uh webinars and weekly tips. But if you're not too interested, but about that, you can just sign up to get the cattle guard and then unsubscribe. I put the link down below for the mind the bleep page where you can find the survival guide? Ok, Petro has asked. So does that mean every morning when a senior reviews the patient, you document in that much detail, if possible? Yeah. So ideally you would want to document in that much detail. Usually you won't be alone on the ward. There will be a team of view of uh usually three or four junior doctors. Maybe you'll be expected to look after 5 to 6 patient's on your own. So that's why it's important maybe to come, come in a little bit earlier or uh than your senior does. So for instance, as a foundation, you're one doctor, I would usually come in 10 to 15 minutes before and briefly prepare the notes when making notes for a new patient on the ward. And using the E D report is a structure for making the notes similar to the structure that you recommend the slides or are there any additional points needed? So to answer this question, question, Richard about clocking in uh new E D patient's most hospitals will, will have a clerking pro former, both in the emergency department or in the am you Acute Medical Unit. Uh follow this clocking pro for however, some hospitals, the pro form is quite vague. In that instance, I would follow that example I've given. But as I've said, uh this is just my example of documenting, you will develop your own style. Uh as you start working as a junior doctor. Do we have any more questions from the audience? Do you have to document if a scan referral has been rejected? Yeah. So it's more important uh sorry to document that the scan has been rejected rather than a scan has been accepted because uh if you document that the scan has been rejected, you can write the name of whoever rejected the scan and then uh like whoever is also looking at this, this patient can re request the scan or will know why the scan hasn't been done. For instance, if the plan for a patient is to get a CT scan, uh and you have you as the foundation, you're one doctor have gone to request a CT scan and it got rejected. Uh The next day when the consultant comes along and the CT scan hasn't happened, they won't know why the CT scan hasn't happened. They might expect the scan to take place later on this week without knowing that it has been rejected. So that has happened a few times uh in my hospital where uh there's been evidence of poor documentation and where we thought that the patient is, was expecting a scan for almost a few weeks when in actual fact, the scan has been rejected and there was no plan to do a scan at all so that just delays patient care. And as you can imagine, it can be quite detrimental to the patient as Well, do we have more questions from the audience? I know there might be a lot of anxiety amongst you guys are starting as a foundation year one doctor. However, it's important to remember that we've all been through this process and you will learn through the job. It will be like uh you'll learn a lot within your first week uh as working as a foundation, you're one doctor and you'll all become second nature to you. Uh once uh you get on the wards. So uh as I said, there's always support available from your senior colleagues which include fy two's up to consultant levels and everyone is quite nice. Uh No one will refuse to help you. So always if in doubt, consult with your seniors and ask for help. So it seems they're normal questions at the moment. Uh For those of you who have tuned in, be sure to keep an eye out for our future webinars will have other webinars on doc you on prescribing. So common uh prescriptions you can be expected to do as a foundation. You're one doctor. We're also expecting to have webinars on common presentations. You can have working in the medical or surgical department. So that will depend on whichever rotation you're starting on first and uh covering uh managing money matters as a foundation year one doctor because it can be quite overwhelming uh starting a new job with this new salary and not knowing how to budget or how to save. So we have different people from the mind the bleep team contributing to this webinar series and we'll be posting regular updates on Facebook. It seems at the moment there are no further questions. So uh I'll let you guys go enjoy the rest of the day and thank you for tuning in uh to this webinar. Uh Best of luck with starting foundation year one training.