On ward round, you will review each patient under the care of your consultant with the rest of the team. A nurse may join you on the ward round so that she is updated on the clinical plan.
What is a patient list?
A patient list identifies all of the patients belonging to your team, where they are located and their key clinical details eg. presenting complaint and relevant investigation results.
When reviewing each patient, as well as asking the patients how they are feeling, their prescription chart and observation chart will be reviewed. One of the team will be documenting the ward round consultation in the patient notes.
At the end of the ward round, the investigations and plans for each patient will be reviewed and tasks allocated. This is an excellent opportunity to make sure you understand the reasoning behind the plans made for each of your patients
What do I do when I am on call?
Being on call can allow you greater input into a patient’s care, but also can be isolating and stressful when you are dealing with a sick patient.
In many hospitals, the on call may start with a team handover, allowing the incoming team a brief summary of key patients needing review or input. This also allows you an opportunity to introduce yourself and find out who will be on call with you as part of the team – so make sure you arrive on time.
As well as the rest of your medical on call team, handover may be attended by the site manager and senior nurse.
Your priority is to identify and prioritise the sick patient and call for help early where relevant. If you have a busy shift, document your tasks to make sure you do not forget anything.
Try to group your tasks by ward/location to prevent yourself going to the same place twice, although this may not always be possible if you are looking after a sick patient.
What does prescribing involve?
Prescription charts may be written electronically or on paper and may be written in outpatient clinics or for inpatients on wards.
Each chart has a section for the patient’s details, allergies, regular, once-only and “prn” (as needed) medications as well as intravenous fluids. Make sure you document any drug allergies and the reaction experienced.
When writing a prescription:
- write the generic drug name clearly as well as the dose (including units),
- write the frequency of administration,
- write the route and times at which the drug should be given (speak to the nurses on the ward if you are unsure when drug rounds occur).
- Sign the entry, including your name and bleep number.
- If you are changing a prescription, cross out the original clearly and then write a new prescription.
What are discharge summaries (TTO – to take out or TTA – to take away)?
Discharge summaries are essential to summarise what has happened to a patient in hospital, as a written record for the patient and their GP.
It includes the patient’s details, consultant team whom the patient was admitted under, presenting complaint, investigation results and diagnosis as well as any procedures/treatments given, medications to continue taking at home and any follow up care that has been organised with the hospital.
As always, make sure you include your name, role and bleep number.
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