23 min

Documentation, prioritisation, and handover Ward Calls

    • Science

Vani and Sam give suggestions on how to improve these everyday skills that can otherwise take a lifetime to learn.

 Why is this important?



* Decisions will be made based on documentation – we are lazy and tend not to verify information.

* Allows you to organise your thoughts, review notes, and identify gaps.

* Is a legal record and part of your job description.

* Inadequate documentation sinks careers.

* You will not remember the details years later if there is a complaint. HDC cases tend to occur years after the fact.

* Prioritisation is an art and is learnt through experience. It is however important to know what the expectations are and not cause harm through poor prioritisation.



Types of documentation



* Ward round notes

* HO notes

* Ward call notes

* Plans

* Lab requests

* Referrals

* Clinic letters

* Procedure notes

* Op notes

* Discharge summaries

* Sick notes

* Supporting letters

* Death certificates



All documentation



* Title

* Date/time

* Reason for review/note

* 1 line summary

* SOAP (Subjective, Objective, Assessment, Plan) or HEIIP (History, Exam, Investigations, Impression, Plan)

* Pertinent info

* Solid plan

* Your name + pager

* Never change a note



Prioritisation



* Let time heal

* Trust no one (nonsensical pages, reflux, nebs)

* Complete non-urgent tasks ward by ward

* Document a plan nurses can follow

* Talk to the nurse

* Hand over a plan with any jobs

* Give a reason for jobs (e.g. fluid review)

* Handover on time, handover your jobs

* Don’t come to work sick

* Perfect is the enemy of good.



Handover



* What makes a good handover?

* Concise and objective

* Clear plan for pending results

* Clear priority

* Concise! Most of what you say will be forgotten, so make it count.

* Why is it important?

* Safety!

* Helps with prioritisation

* Opportunity to discuss cases with a colleague

* Allows you to relax and sleep after you’ve gone home

* What is appropriate to handover?

* Jobs to be done

* Investigations to be chased and plan

* Patients to be reviewed

* Sick patients

* Patients expected to die

* Patients for whom you feel additional context would be useful. Don’t just hand over patients the next house officer “might get paged about”.

* Go home on time.

* Weekend plan

* Prepare discharge summaries and referrals

Vani and Sam give suggestions on how to improve these everyday skills that can otherwise take a lifetime to learn.

 Why is this important?



* Decisions will be made based on documentation – we are lazy and tend not to verify information.

* Allows you to organise your thoughts, review notes, and identify gaps.

* Is a legal record and part of your job description.

* Inadequate documentation sinks careers.

* You will not remember the details years later if there is a complaint. HDC cases tend to occur years after the fact.

* Prioritisation is an art and is learnt through experience. It is however important to know what the expectations are and not cause harm through poor prioritisation.



Types of documentation



* Ward round notes

* HO notes

* Ward call notes

* Plans

* Lab requests

* Referrals

* Clinic letters

* Procedure notes

* Op notes

* Discharge summaries

* Sick notes

* Supporting letters

* Death certificates



All documentation



* Title

* Date/time

* Reason for review/note

* 1 line summary

* SOAP (Subjective, Objective, Assessment, Plan) or HEIIP (History, Exam, Investigations, Impression, Plan)

* Pertinent info

* Solid plan

* Your name + pager

* Never change a note



Prioritisation



* Let time heal

* Trust no one (nonsensical pages, reflux, nebs)

* Complete non-urgent tasks ward by ward

* Document a plan nurses can follow

* Talk to the nurse

* Hand over a plan with any jobs

* Give a reason for jobs (e.g. fluid review)

* Handover on time, handover your jobs

* Don’t come to work sick

* Perfect is the enemy of good.



Handover



* What makes a good handover?

* Concise and objective

* Clear plan for pending results

* Clear priority

* Concise! Most of what you say will be forgotten, so make it count.

* Why is it important?

* Safety!

* Helps with prioritisation

* Opportunity to discuss cases with a colleague

* Allows you to relax and sleep after you’ve gone home

* What is appropriate to handover?

* Jobs to be done

* Investigations to be chased and plan

* Patients to be reviewed

* Sick patients

* Patients expected to die

* Patients for whom you feel additional context would be useful. Don’t just hand over patients the next house officer “might get paged about”.

* Go home on time.

* Weekend plan

* Prepare discharge summaries and referrals

23 min

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