It takes time to get used to the ward round. Particularly, when patients are being seen so fast it seems impossible to document properly. The most important tip is to ask your colleagues currently doing the job to explain how it works and any tips they have. FY1s also frequently contribute these explanations & tips to Dr Toolbox.
In this article, we will talk about the three stages of the ward round with tips on efficiency: preparing notes, recording and creating a jobs list. Before the ward round, there’s frequently a multidisciplinary team (MDT) meeting where you run through all the patients. The aims include identifying:
- New patients so the team are aware of why they’re in, which consultant is looking after them & their functional baseline
- Unwell patients who need their review prioritised
- Medically fit patients to identify outstanding jobs and complete discharge planning
The Ward Round
Ideally, you should be guiding the team to ensure all patients are seen. The aim is to document appropriately what occurs such that anyone from the MDT knows the plan. It is worth handing over the plan to the nurse looking after the patient and/or the nurse in charge. If they’re aware of the plan, they will work with you to look after the patient, it’ll reduce their need to bleep you and they might update families with the plans so you don’t have to if you’re busy.
At first, you might feel the ward round is chaotic, particularly due to interruptions and the speed at which you see patients but this will improve. It is important you ask your seniors for support or to slow down as you need. It is in their best interests that you understand the plan and are able to document it as they have ultimate responsibility for a patient. Therefore, if you feel unsupported you need to discuss this with them.
Ideally, aim to prepare the notes before the ward round starts. This isn’t always possible because often your shift starts at the same time as the ward round. You should NOT come in earlier than your start time to prepare notes as this can lead to burnout. If you’re finding the need to arrive early, then either your work schedule needs changing to accommodate this or your seniors need to start the ward round later. This is why exception reporting was brought in: to prompt these discussions and to support changes.
Whether or not you do prepare, it is very important to have a set proforma in your head, with very clear headings, and spacing that would ensure you remember everything for every patient. Additionally, try to write a summary of the case at the start of the week, so you, the MDT and the on call team have something to fall back on.
Before preparing the notes, ensure you read if anything has happened overnight or documentation from any other members of the MDT (e.g. pharmacy, OTs, PTs, dieticians or specialist teams).
Include the following in your ward round entry:
- Patient’s details either using a label or writing their name, date of birth, sex, and hospital number.
- Date & Time
- Name and grade of the one leading the round (and other team members that are present)
- Problem list: make sure to include all problems in this admission, including resolved ones, which will help you massively when writing the discharge summary. At least, write all active problems.
- NEWS: make sure you write down any abnormal observations and if the patient is stable or not.
- Not everyone adds this, but I like to include bowel, fluid balance, and food on the surgical ward round
- Blood results +/- important investigation
- I add an area of free text just in case
- Examination: include drains, catheter or urine output
- Your signature, grade, name, GMC, most importantly your bleep (for the MDT)
Please see Figure 1 below as an example of headings and spacing on the page. Many people have their own way of writing this, this is just one of the way I got stuck into. Please note that some wards have standard proforma for ward rounds.
The aim is to record what has occurred during the ward round. Medical notes are legal documents and it is quite easy for patients to request them. Ensure you write something you’d feel comfortable saying out loud to the patient or their relatives.
- Do not bring notes into an isolation room
- If charts are by the bedside, record in your notes the NEWS chart, fluid chart, diet chart and blood glucose
- Review the drug chart. Pay attention to antibiotics (clarifying duration & when to switch to oral), any medications that are no longer needed, adjusting analgesia and checking that VTE is prescribed.
- Examination: Put down the general appearance of the patient & don’t be scared to ask your seniors if the findings are unclear: “Mr/Dr what are your findings on auscultation?”
- Impression: This is your diagnosis or DDx – it is an incredibly useful part of the documentation. If you’re unsure what to write ask your seniors. Include if the patient is MFFD / MOFD or the estimated discharge date
- Plan: Use bullet points & write detailed plans
- Consider whether you need to review any blood results
- Do consider their diet requirement (do they still need to be nil by mouth?)
- Consider whether treatment escalation or DNAR needs completing
Figure 2 is a fictitious example of documentation. There are several points I would like to draw you to:
- Writing the date of major events (such as surgery) makes life much easier in an emergency
- Write the number of days a patient has been on antibiotics to guide switching to oral therapy
- Keep a list of resolved issues as well to help you write a discharge summary & in case the issues reoccur
- Do include the drain or catheter output and fluid colour
Ideally, rank your jobs in order of priority. Sick patients should be your highest priority as they can deteriorate. Next is organising urgent scans as the schedule for the day is set often very early in the morning. Finally, completing discharge medications before the summaries can ensure there’s enough time to organise these from the pharmacy department.
For time-critical jobs such as drug levels, do write down the time to plan your day optimally. Additionally, it can help to identify jobs that if needed can be done the next day.
In Figure 3, you can see I have numbered tasks in order of priority with small boxes to indicate completion. Doctors frequently use half-filled boxes to indicate partial completion e.g. bloods taken but result pending.
Managing interruptions on the ward round
Often you will be interrupted on the ward round. This can make it difficult to follow what is being said resulting in you missing vital things to document. However, it might be a nurse escalating a very unwell patient and therefore you need to reach a careful balance.
Many interruptions can be managed simply by providing the nursing team with a handover at the end of your ward round or explaining that you’ll add the task to your job list. Here are some common questions and how you might approach them.
Q: Can the patient eat, and drink?/ Is patient NBM?
A: Consider why the patient needs to be NBM? Post-op? Pre-op? For scans? Scan done? Procedure?
Q: Can you prescribe some IV fluids, please?
A: Can the patient drink? Are they hypotensive/tachycardic i.e. shocked? Often if they can drink they do not need IV fluids (unless the fluid is to correct an issue like deranged electrolytes)
Q: Antibiotics on day X needs review, can we give next dose?
A: WCC and CRP levels? Culture results back yet? Patient improving clinically?
Q: Can we give enoxaparin?
A: VTE assessment done? Pre-op? Post-op? Bleeding risk? Active bleeding?
Q: The drug chart needs reboarding & I need to give the medication now.
A: Any urgent medication can be prescribed as a stat dose. Otherwise, this can wait and be added to your job list.
Q: The patient needs a discharge summary, please?
A: Ask when the patient is likely to be discharged in order to prioritise it appropriately. Explain that you will add it to your job list.
Q: The cannula isn’t working, can you place a new one?
A: Often senior nurses or medical students may be able to place the cannula. Always consider whether it is necessary (can the fluids be stopped? can the medication be switched to oral?) and if they’ve tried flushing as this might unblock it. If a patient is difficult to cannulate and will need it for a long duration or on discharge, consider requesting a midline or PICC line.
Q: The catheter is not working. Can you put another one in?
A: Ensure it has been flushed. Request that the nurses do a bladder scan to see if there’s retention.
A list of abbreviations that you may come across, or use for speed:
Abx = Antibiotics
1/7 = 1 day
1/52 = 1 week
1/12 = 1 month
BM = blood serum glucose test, BM actually stand for Boehringer Mannheim, a brand name
NAD = no abnormality detected
NBM = Nil by mouth
HR = Heart rate
RR = Respiratory rate
95% OA = 95% saturation on room air (please put room air)
SNT = soft non-tender
MFFD = medically FIT for discharge (does not mean can go, can have social issues. Also FIT can be interpreted as not on medical treatment)
MOFD = medically OPTIMISED for discharge (this is a better term, meaning the management had been OPTIMISED for the purpose of discharge)
PT = Physiotherapy
OT = Occupation Therapy
TWOC = Trial Without Catheter
FU = follow up
R/v = review
DC = discharge
CH = community hospital
POC = Package of care
?something = suspected something
- Prep the notes with headings
- Read the last entry
- Recording your findings and go through a checklist
- Make a job list and rank items in order of priority
- Handover to nurse, to let them know the overall plan, and their responsibilities.
- Consider a 2 minutes break to drink some water before you embark on your jobs
By Alexander Tam (FY1)
Edits by Dr Akash Doshi (CT2)
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