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Daily wardduties
Firstthing
• You’re expected to be the rst doctor on the ward in the morning
• Ask the night team (nurses and doctors) about any events overnight
• Submit any missing or extra blood/ CXR/ ECG requests
• Personally review any new or acutely unwell patients.
Wardround
• E pp. 74–5 for ward round duties, try to keep a jobslist
• You can try to start simple jobs (eg TTOs, requests) during the
wardround, but avoid disrupting the ow of patient reviews.
After thewardround
• Spend a few minutes comparing and allocating jobs between the team
members. Try to group jobs by location, urgency, and skillset
• Radiology requests (USS, CT,MRI)
• Referrals to other teams, eg surgery/ cardiology/ psychiatry
• Complete TTOs early—allow pharmacy time to prepare the drugs
• Take blood from patients whom the phlebs have been unable to bleed,
that were requested during the wardround, or needed urgently.
Lunch
• Do you need to do anything for yourself, eg book holidays, paybills?
• You may have teaching/ grand round/ journalclubs. Get some fresh air!
Afterlunch
• Review patients you are worried about. Liaise with nurses about any
problems they have identied and attend to routine tasks they mayhave
• Check and record blood results; serial results sheetshelp
• Check other results; chase outstanding requests or results
• Spend time talking to patients ± relatives
• Submit blood and other investigation requests for the nextday
• Check the patients’ drug cards— do any need rewriting?
Before you gohome
• Review results and outstanding jobs with other team members; make
a note of anything that needs doing the nextday
• Check that all warfarin and insulin doses have been writtenup
• Prescribe sucient IV uids for patients overnight where safe todoso
• Handover patients who are sick or need results chasing by the on-
call team (E p. 88); write down their ward, name, DoB, and hosp.
number and what you want them to do (ie not just ‘check bloods’).
Before weekends
• Only submit blood requests for patients who really needthem
• Try to prescribe 3 days of warfarin doses where safe todoso
• Make sure that no drug cards will run out over the next 2 days, rewrite
them if they will (this is not an appropriate on- calljob)
• Handover to the weekend team according to local protocol; thorough
patient summaries on Friday ward rounds help the weekend team
immensely. Make sure they are aware which patients are unwell and
what the weekend plans are (eg escalation plans if they deteriorate).
73DAILY WARD DUTIES
74 CHAPTER2 Life onthewards
Wardrounds
A smooth ward round requires thought and careful planning, with preparation of notes, investigations, and results (Fig. 2.). The speed of a
ward round can vary greatly depending on the senior clinician leading it.
For guidance on reviewing patients in between ward rounds see Box 2.2.
Before thewardround
• Update the patient list with patient details, location, summary of
clinical problems, key investigations/ results, referrals made, andjobs
• Ask the nurses if any patients have changed condition overnight and
try to avoid any nasty surprises on the round
• Check notes, drug cards, obs charts, X- rays, and blood results are present
• Clearly document all relevant investigation results and reports in the
notes with a brief summary on your patientlist
• Check all notes have continuation sheets headed with the patient’s
name, DoB, and hospital number/ address (use a hospital sticker)
• Consider writing out the patient’s problem list/ summary beforehand
• If your patients have moved, nd out where they have been transferred
to and plot an ecient route through the hospital to visit all your outlying
patients
• Check or chase the dates/ times for outstanding investigations
• Learn your consultant’s favourite questions from your predecessor
• Consider multidisciplinary issues which may alter further management
or delay discharge for the patient (eg home situation, see Box2.)
• Think about management dilemmas you want/ need answersto.
During thewardround
• It is good to have a nurse join the ward round, both for their
contributions and to aid handover. If they’re too busy, handoverlater
• If there are two junior doctors then one can prepare the notes, obs,
drug cards, and X- rays for the next patient while the other presents
• When presenting a patient, always begin in the same logical way, eg
‘Mrs Smith is a 64- year- old lady who presented with a 4- day history of
worsening shortness of breath’ then proceed to past medical history,
investigation, blood results, and then managementplan and summary
• If you have a spare moment, start lling in forms or doing the jobs
generated on the ward round (eg prescribing uids)
• If you have any queries about the next step of management or
investigation results, ask during the ward round. Also ask about
rationale for imaging if unsure as this makes requesting imaging easier
for you (E p. 81)! ... ‘Just for my learning, what is the reason for...?’
• Referrals made in the presence of your consultant are often more
readily accepted and queries can be discussed directly
• If you have not done something or cannot recall details, be honest.
After thewardround
• Discuss with your team the plan for the day. You may need senior help with
some jobs (eg if there are too many or you need specic input). Seniors may
need to go to theatre or clinic. Time permitting, try to join occasionally:extra
educational opportunities like this are good for your career planning aswell
• Prioritize the jobs and group by location, eg outlying wards, radiology
• Clarify any gaps in your understanding of the patients’ management.
75WARD ROUNDS
Fig.2. Example of a sample patient list and a ward round entry in the patient’s notes.
Box 2. Discharge planning
This is a multidisciplinary process that should start on admission and continue throughout. Medical, discharge planning, and therapy teams complete social needs assessments, asking 4 key questions: (i) what support
is there? (ii) Now they have become unwell, do they need more? (iii) Is
there potential to improve? (iv) Where would they prefer to go? We aim
to give patients both safety and independence. Options include (i)social
care (from home adaptations, mobility aids, and home carers to residential
homes and nursing homes), (ii)intermediate care for those with potential
to improve (home re- ablement, rehabilitation, or community hospitals),
and (iii) community healthcare (district nurses, nursing agencies, and community therapy). It is a complex process due to variations in personal preferences, family situations, local services, national structures, and funding
streams, but take the time to learn the local process. Your contribution to
this important multidisciplinary conversation can be critical and failure to
engage will inevitably lead to discharge delays.
76 CHAPTER2 Life onthewards
Writing inthenotes
Most new Fs are unsure about writing in medical notes since this is
rarely practised as a medical student. Whether writing in paper notes or
on an electronic medical record, there are a few rules which everyone,
irrespective of grade, should conform to (Fig.2.3):
NotepaperThe patient’s name, DoB, and hospital number or address
should identify every sheet (using a hospital sticker is preferable).
Documentation Each entry should have the date and time. It is useful
to have a heading such as ‘WR ST2 (Smith)’ or ‘Discussion with patient and
family’. Sign every entry and print your surname and bleep number clearly.
Structure When you come to review an unfamiliar patient, a well-
structured, informative entry in the notes makes your job a lot easier. Learn
from good examples and develop a structure for your own entries with this
in mind. Subheadings and bullet points are useful ways to convey information clearly. Write a problem list and update it regularly so that on-call teams
can understand your patient quickly if they are asked to review them—this
should include both medical and social problems. See Fig.2.2. Always nish
with an impression and a plan.
What to write The notes should contain enough information so that in
your absence someone else can learn what has happened and what is planned
for the patient. Try to document everything that is discussed or observed—
the information discussed in conversations may be important medicolegally.
As far as a court is concerned, if it’s not documented then it didn’t happen.
Write clearly in black ink.
What not to write Patients can apply to read their medical notes and
notes are always used in legal cases. Never write anything that you do not wish
the patient to read or that would be frowned upon in court. Documenting
facts is accepted (eg obese lady) but not subjective material (eg annoying timewaster). Never doodle in the notes and do not write humorous comments.
Making changes If you wish to cross something out simply put a
single line through the error and initial the mistake. Never cross it out
so it cannot be read as this looks suspicious. Previous entries should not
be altered, instead make a new entry indicating the change or dierence.
Fig.2.2 Example of a problemlist.
Fig.2.3 Example of entries in medicalnotes.
77WRITING IN THENOTES
Box 2.2 The daily review
The frequency of consultant- or registrar-led ward rounds varies, sometimes
every day, sometimes only once or twice per week. It falls to the junior members of the team to review the patients on the days in between. There are
several things to consider and document when reviewing a patient:
Background Demographics, background and comorbidities.
Admission details Reason for admission, problem list, and any updates.
Investigations Results and those that are pending (it is your responsibility
to chase these).
Chart review Do antibiotics need reviewing? Check VTE prophylaxis,
adjust medications to changes in renal function.
Observations Look for any trends.
Today How the patient is doing today. Any new issues? Do they under-
stand what is happening in hospital?
Examination Document the ndings of your examination.
Impression Document the diagnosis and overall progress.
Plan List any outstanding procedures, investigations, or treatment.
Consider discharge planning.
78 CHAPTER2 Life onthewards
Common symbols inthenotes
Home
Normal
Plan
Left
Right
dd/ DD/ δδ/ ∆∆ Dierential diagnosis
x/ Dx/ ∆ Diagnosis
Imp Impression
Rx Prescription or drugs
Sx Symptoms
Tx Treatment
Ix Investigations
O/ E / OEx On examination
– ve Negative
+ve Positive
+/ – Equivocal
+ Presence noted
++ Present signicantly
+++ Present in excess
h/ o History of
d/ w Discussed with or discussion with
WR Ward round
r/ v Review
f/ u Follow- up
ATSP Asked to see patient
IP In- patient
OP Out- patient
c/ o Complains of or complaining of
Pt Patient
–
c
@ At
E+D Eating and drinking
N+V Nausea and vomiting
D+V Diarrhoea and vomiting
BO Bowels open
PUing Passing urine
blds Bloods
x/ −
°/
° Primary
2° Secondary
mane Tomorrow morning
N/ S Nursing sta
Temperature
With
No/ negative (as in °previous MI)
Anatomical terms andplanes
79ANATOMICAL TERMS AND PLANES
The anatomical position
Coronal or
frontal plane
Fig.2.4 The anatomical position and anatomical planes.
Anatomical planes
Sagittal plane
Axial, transverse,
or horizontal
plane
Table2. Commonly used anatomical terms and their meanings
Anterior/ ventral Front of the body
Contralateral On the opposite side
Coronal/ frontal plane Di vides anterior from posterior
Distal Away from the trunk
Inferior/ caudal Away from the head
Ipsilateral On the same side
Lateral Away from the midline
Medial Towards the midline
Palmar Pertaining to the palm of the hand
Plantar Pertaining to the sole of the foot
Posterior/ dorsal Back of the body
Prone Face-down position
Proximal Close to the trunk
Radial The lateral (thumb) aspect of the forearm
Sagittal plane Divides left side from right side
Superior/ cephalic Towards the head
Supine Face-up position
Transverse/ horizontal/ axial plane Di vides upper and lower sections
Ulnar The medial (little nger) aspect of the forearm
80 CHAPTER2 Life onthewards
Investigation requests
These are almost always handled electronically. For paper forms, complete:
• Full name and at least one other patient identication detail (ie DoB,
hospital number, or address); G+S/ X- match requires at least twomore
• Status (in- patient/ out- patient) and location (ward or home address)
• Name, position, and contact details of doctor ordering thetest
• Date, test(s) requested, and reason for request.
Clinical informationAppropriate information on request forms af-
fects how the test is performed and reported; too much information is
better than too little. Justify the investigation requested. Always consider
if a test is really required, no matter how trivial— daily ‘routine’ bloods
are often unnecessary, waste resources, and cause patient discomfort.
Blood tests Brief clinical details may be acceptable, eg ‘chest pain’, ‘sus-
pected PE’. Some tests require more information, eg blood lms, antibodies, hormones, drug levels (doses and timing of doses), genetics.
Histology Describe the macroscopic appearance of the tissue as well as
the clinical suspicions, radiology ndings, and any specic questions.
MicrobiologyAs a bare minimum include the sample type (eg urine) and
current/ recent antibiotics; the more information you include, the better
the microbiologist will be able to interpret laboratory results.
Radiology Ep. 81.
T Box 2.3 ‘Chasing’ results
As a junior doctor, a large proportion of your time will be spent checking results.
This used to involve ‘chasing’ endless pieces of paper which were prone to going
astray. With the move to full computerization, most reports are now easily available:simpl y keep track of the investigations you have requested then check the
results systems regularly. Nonetheless, there are a few tips to consider:
• For urgent results, particularly where there might be a delay in transcription
(eg radiology reports) or uploading onto the system (eg biochemistry/
haematology), you can call the lab, or reporting room (or attend in person). You
will be interrupting a colleague doing their job, so do not abuse this privilege
• Blood samples reaching the lab early in the day will be processed rst; it can help
to beat the rush that will hit the labs after the phlebotomists do theirrounds
• Rarer tests may only be run on samples reaching the lab by a certain time, or
on certain days of the week, or may even need to be sent to an outside lab—
nd out local policies and, if in doubt, call the lab before taking thesample
• Bloods requiring urgent processing should be marked as such; indiscriminate
use of this facility will delay genuinely critical results. Arrange an urgent
porter (or take to the lab yourself). At top speed, biochemistry results take
around 20– 30min and haematology results around30min
• For microbiology results, preliminary evidence of positive cultures is usually
reported at 48h; otherwise consider telephoning the lab at this stage to see
if there is any preliminary growth. Positive results will be further cultured and
tested over subsequent days to give a more detailed analysis
• For histology, all biopsies taken with a provisional diagnosis of malignancy
should be processed urgently, but this depends upon the sample being correctly
marked at the time; call the pathology secretaries if there is any doubt ordelay.
Be careful not to make important decisions on preliminary results— if there is
an urgent clinical situation in which you are unsure whether to act on a specic
result, ask your seniors.
Radiology
Imaging modalities
X- raysThese exploit the dierent absorbance of a pulse of X- ray radiation
by dierent anatomical structures and foreign bodies (Box 2.4). This allows
the visualization and distinction of metal, bone, soft tissue, fat, uid, andair.
FluoroscopyThis uses X- ray images acquired in real time, often with add-
ition of a contrast material, eg coronary angiogram or barium swallow.
CTThis uses a series of 2D X- ray images acquired in dierent planes to
construct cross- sectional 3D images. IV or PO contrast can be used to
accentuate, eg blood vessels or the GItract.
MRIThis uses strong magnetic elds to align hydrogen nuclei (protons)
within tissues. Disturbance of the axis of these protons by radiowaves
allows the recording of radiowaves emitted as the protons return to
baseline. MRI oers excellent soft tissue imaging and does not require
ionizing radiation exposure. Image acquisition can be slow and require
multiple dierent ‘sequences’ while the patient lies in a crampedspace.
Ultrasound This exploits the dierential reection of high- frequency
sound waves to visualize structures, including soft tissues in real time.
Overlying air and fat compromise signal quality, and bone penetration
ispoor.
Nuclear medicine This depends upon the detection of radiation emitted
by the decay of radiolabels attached to substances with anity for certain body tissues. Positron emission tomography (PET) is a specic form of
nuclear medicine that typically uses radiolabelled glucose analogues to
detect regions of metabolic activity, eg in cancer. These techniques are
especially powerful when combined with anatomical imaging approaches
such as CT/ MRI to increase localization (eg PET/ CT or PET/ MRI).
Requesting Communicate patient information and the clinical question to
be answered clearly on the request form, this gives context for the reporting
radiologist who has to interpret the images. Some scan requests have to be
vetted by a radiologist before they will be done. Check local hospital policies
in and out of hours. Always ensure you know why any investigation you
are asked to request is needed, how urgent it is, and how it will change the
patient’s management. For chasing up results, see Box 2.3.
81RADIOLOGY
K Box 2.4 Radiation doses from medical imaging
The average radiation exposure from natural sources in the UK is
~2.7mSv/yr. Converting low-dose radiation exposure to cancer risk
is fraught with diculty, hence the general principle must be to keep
exposure As Low As Reasonably Possible (ALARP).
• Limb/joint X-ray <0.0mSv
• CXR 0.04mSv
• AXR 0.7mSv
• CT head .4mSv
• CT chest 6.6mSv
• CT abdomen/pelvis 0mSv
Mhttps://www.gov.uk/government/publications/medical-radiation-patient-doses/
82 CHAPTER2 Life onthewards
Discharge summaries (TTOs/ TTAs)
‘TTOs’ or ‘TTAs’ (to take out or away) are summaries of the patient’s
admission from the ward doctors sent to the patient and their GP. TTOs
are usually written on a computer; you should receive training on the local
system as part of induction. They form a point of reference at future clinic
visits or admissions. They also provide clinical coding information which is
used to calculate payment for the hospital. See Box 2.5.
Box 2.5 TTOs should contain thefollowing information
• Patient details:name, DoB, hospital number, address
• Consultant and hospitalward
• Presenting complaint, clinical ndings, and diagnosis
• Investigations/ procedures/ operations/ treatment, including any
complications
• Treatment on discharge and instructions to the GP, including all
medications started or stopped and reasonswhy
• Follow- up arrangements (be clear who is responsible forthese)
• Your name, position, and bleep number.
Writing TTOsTTOs should be written as soon as you know the patient is
likely to be discharged soon. This allows the drugs to be dispensed from pharmacy as soon as possible so that the patient’s discharge is not delayed (Fig.2.5).
• Begin to enter information on the TTO at the earliest opportunity; check
any queries with your team, particularly regarding the principal diagnosis
• Check the duration of the medication for discharge (eg ABx) and stop
any unnecessary drugs (eg prophylactic low- molecular- weight heparin)
• Check drug doses and frequencies with the BNF, your seniors, a
pharmacist, or by calling your hospital’s drug information line
• Check required follow- up appointments, give details, and be clear on
who will arrange them (eg the ward clerk or the clinic administrators)
• Phone the GP if the patient needs an early check- up, has a poor social
situation, or self- discharges. It may take several days for a TTO to reach
the GP:written instructions such as ‘check K
• Some patients have extra requirements such as a ‘blister pack’ or
a medication administration record (MAR) chart, used by district
nurses. Identify these patients early as they may require extra forms
or additional time for preparation in pharmacy.
• Discuss the diagnosis, results, and discharge plan with your patient; if
they understand the management plan they are more likely to comply.
Controlled drugs forTTOsThese are drugs subject to a higher level
of regulation. In most trusts, they can still be written or typed by an F
but the prescription of schedule 2 and 3 drugs must meet certain requirements. These prescriptions must contain:
• The name and the form of the drug (eg capsules or tablets)
• The strength of the preparation (eg 50mg capsules)
• The dose to be taken (eg one tablet once per day)
• Total quantity of the preparation to be supplied in words and gures
• The prescriber’s signature and address.
No more than 30d supply should be prescribed, and prescriptions are
only valid for 28d from the date of signing. See Box2.6 and Fig. 2.6.
+
in 3/ 7’ areunsafe