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Daily Activities

Writing in notes

  • Always write legibly in black, quick-drying ink.
  • Make sure the patient details and location are on the sheet.
  • Avoid abbreviations.
  • At the start of your entry, include the date and time (left hand column) and your name and grade, or if writing for someone else – their name and grade.
  • At the end of the entry, include your signature, name, grade and bleep number
  • If you make a mistake cross it out with a single line, and write the date, time and your signature.
  • If you go over the page, write PTO or continued at the bottom of the first page, and write the date, time and your name again, and “continued” at the top of the next page.
  • You should always document at the time of review if possible. If you are delayed in documenting (e.g. called away to an emergency), record the time of documenting in the usual place and on the first line of your review, write “Written in retrospect, reviewed at XX:XX”.

Structuring review documentation

It is useful to start with a short summary, e.g. the patient's age, gender, what they were admitted with, problem list and relevant PMH. There are a couple of ways to structure a daily review, I’ve outlined one suggestion here:
“SOAP” - Subjective/Objective/Assessment/Plan:
Subjective:

  • How is the patient feeling? Are their symptoms better or worse? Are there any new issues?

Objective:

  • Observations, blood sugars, urine output, weight
  • Examination findings
  • Investigation results

Assessment:

  • Impression – There may be multiple impressions or problems and it’s ok to have two possibilities that you’re considering.
  • Are they improving or worsening?

Plan:

  • Investigations to request
  • Anything to monitor and how often (e.g. hourly urine volumes, daily weights)
  • Referrals to make
  • Any AHP review needed (e.g. physiotherapy)
  • Treatment to initiate or change
  • If they need review before the next routine daily review, document when and with whom.
  • On a Friday, document what frequency and level of review is required over the weekend (e.g. daily bloods, daily review by junior or daily review by senior)

Senior ward rounds

  • It is helpful to have two juniors and two computers – everything is slicker if one person can prep the next set of notes and get everything open on the laptop whilst the previous review is happening. Try to split it so that you are seeing the patients that you know.
  • Make sure you have a patient list or a sheet of paper with space to write all the jobs before you start and use the “box system” - empty when job is to be done; half-filled once started; filled in when completed.
  • Don’t be afraid to ask for clarification – e.g. is that CT urgent?/what is the question for this referral?/what is the duration of these antibiotics?/what follow up do you want for this patient?
  • Hand over to the nurses – preferably at the end of the ward round.
  • Don’t forget that this is a learning experience for you as well. Ask questions, request feedback on your previous plans for the patient, get your seniors to explain their thought processes.

Doing your own reviews

Much of the same applies as when you are on a senior ward round. Make sure you have a structure and are thorough. Pause at the end of each review and ask: Have I seen the drug chart, bloods, imaging, observations, weight, urine output, bowel chart and blood sugars? At first you will be the slowest person on the team – that’s ok. Over time you will get quicker.
Take the time to read the notes and review the relevant info (bloods/obs etc) before you see the patient – it will save you time in the long run and mean you’re prepared for the patient asking you questions.

Don’t be afraid to ask questions of your seniors – you don’t have to make all the decisions yourself. If not urgent, try to keep a list of questions to ask at once. It’s ok to write in the notes “?would be suitable for OPAT – will discuss with senior”, for example.

Let the patient know your plan. Again, it is ok to say to them, “I’m not sure what the best plan is, I will discuss with my senior and let you know” - but give them a reasonable idea of when you will know (i.e. this afternoon, not in 5 minutes) and make sure you go back to update them.

Prioritising jobs

After the ward round, it’s best to go over the jobs list with the other juniors, split the jobs up and prioritise the most urgent ones. You have to prioritise based on the jobs you have in front of you, but a good starting point is:
Deteriorating patient → urgent requests (investigations/referrals) → discharge letters → routine requests → preparing discharge letters for the following day (if you can do this, your life will be easier and everyone else will love you). Don’t forget to prioritise lunch in there somewhere as well!
Near the end of the day, review your list and check you’ve done all the jobs. Put anything that there hasn’t been time for and that can wait on the handover. Go through each patient to check that you’ve seen their bloods for the day, updated the eWhiteboard and put bloods out for tomorrow if needed. Make sure you put anything outstanding for the evening on the whiteboard as a task.

Prescribing

Some general prescribing tips:

  • If you’re not sure of a dose/frequency, look it up in the BNF (get the app!).
  • Pharmacists are a great source of information on drug interactions/monitoring etc.
  • Always put stop or review dates on short medication courses.
  • If asking for review/withholding a medication, it is very helpful to put the reason.
  • If a medication has a specific instruction, always write it in the comments box, e.g. “Not for discharge” or “Long term for UTI prophylaxis”.
  • Things that might alter medications you prescribe are renal or hepatic impairment, frailty, poly-pharmacy and extremes of body weight. These are worth bearing in mind when prescribing new things.
  • If doing calculations double check and consider asking someone else to check it too.
  • For advice on how to prescribe on Lorenzo, see IT section.
  • For advice on prescribing IV fluids please refer to the NICE guidance: Intravenous fluid therapy for adults in hospital https://www.nice.org.uk/guidance/cg174. There is a helpful algorithm you can follow which can be found under the Tools and Resources tab.

Tips for a good TTO/Discharge Letters

Remember that the main “audience” is the GP. Other people who will use these are doctors in clinics and on subsequent admissions. It’s important to be concise so the important information is easy to find, but also to include all vital information – a difficult balance. Try not to use abbreviations, both because they might not be universally understood and because of coding.
Include:

  • Reason for hospitalisation – with specific principal diagnosis or diagnoses.
  • Significant past medical history
  • Significant investigation results
    • It can be tricky to know what is “significant” - include important positives and negatives. Think about what you would want to know if you were the GP or the next doctor to see them. E.g. it doesn’t matter exactly what their CRP was, but it is helpful to know that an ECG showed AF for the first time, or that a CT brain was normal.
  • Procedures performed
  • Brief overview of clinical course and treatment.
    • Similar rules apply regarding what is “significant” - would it be helpful to know in the future/for the GP?
  • Was it a prolonged admission and if so why (e.g. difficulty finding a placement)
  • Any medication changes, reasons and any new allergies clearly documented
  • Outstanding results
  •  Actions for GP:
    • Be clear and specific. E.g. “GP to recheck U+Es in 1 week to ensure potassium has stayed in normal range. We have spoken to Mr X and he will make an appointment for this” is better than “U+Es 1 week”. It’s always worth asking the patients or their relatives to make any appointments - less work for the GP practice and more likely to happen in time.
  • Follow up:
    • Follow up by the speciality under which they are admitted can be arranged by the ward clerks
    • For other specialities, send a referral letter (sometimes a copy of the discharge summary will do)
    • If you want the GP to arrange or follow up anything, this needs to be very clear (and is there a reason why we can’t arrange it?)

How to make a good referral

Many inpatient referrals are now on ICE. If not, or if you have an urgent query, you can bleep.
You need to know what the actual reason you’re referring is. If you don’t know or you’re not sure, check with the person who asked you to make the referral (better than having to call twice!)

  • Do you want advice? Inpatient review? Them to take over care?
  • What is the specific question?
  • What are your/the teams concerns re: this patient?

Make sure you know or have:

  • The history and examination findings
  • The current plan
  • The medical notes
  • Recent observations and trend
  • Recent blood/imaging/other results and trends
  • Escalation status and usual baseline function

Use SBAR to help you structure your request. Sometimes it is easier to jot a quick SBAR down before picking up the phone.

Requesting and reviewing results of investigations
See investigation section of junior doctor handbook.

How to bleep
See how to bleep section of the Junior Doctor Handbook.

How to use the pod
See how to use the pod section of the Junior Doctor Handbook.

Using the different IT systems
See the IT section of the Junior Doctor Handbook.

Making your colleagues on call shifts easier
Before leaving for the evening or the weekend, you need to put tasks on the Whiteboard for any patients who need a review or any investigations that need taken or chased, and ensure:

  • Any medications that need to be individually prescribed (e.g. warfarin) have been prescribed if possible. If it is not possible to prescribe medications before you leave, ensure you request the relevant blood tests and put a task on the board for someone to chase and prescribe. Often, warfarin can be prescribed for several days at a time. Patients may need more frequent INR checks if:
    • New starter
    • Labile INR
    • On a medication that commonly interacts (eg clarithromycin)
    • Deranged LFTs
  • Fluids are prescribed overnight or for the next 24 hours if possible. If a review is needed, put a task on the Whiteboard with information as to why e.g. recheck blood pressure/fluid status.
  • Any possible discharges have TTOs completed.
  • The Whiteboard is up to date and the nurses know about the plan for the patient.
  • An escalation status is in place and documented (this is a senior decision, but something that you can highlight, e.g. on ward rounds or if a patient is deteriorating).