Teaching session It is helpful to base a topic around a patient if this is appro- priate. K eep the session interactive; have question slides where the audi- ence can discuss answers. Summarize with learning points; it is helpful to provide a hand-out of your slides for peo ple to take away (b p63). _OHFP.indb 61 _OHFP.indb 61 30/05/2014 16:17 30/05/2014 16:17 62 CHAPTER 1 Being a doctor Giving the presentation Equipment Ensure that the projector/computer you need will be avail - able well in advance. Ideally check it works and leave enough time to fi nd new equipment if there is a problem. Timing Arrive early and check your slides project correctly. Leave the title page projected so the correct audience attends. Speaking You need to talk loudly enough to be heard at the back of the room. This can be da unting, but a good presentation given inaudibly is more disappointing than a poor presentat ion delivered audibly. Body language Stand at the front of the audience and avoid walking into the projected image . Direct your talk at the audience, not the screen. This makes you appear more confi dent a nd also allows you to gauge if people are confused or bored. Try to make eye contact with e veryone in the room. Beginning Introduce yourself and your position, outline the topic you are going to talk abo ut, and explain why you chose the topic. This is a good time to interact with the audience; ask if people at the back can hear you. To use notes or not You should not need notes to prompt you but have them available; points on the slides should be enough. Style Keep it professional, but show you are human; it is acceptable to be light-hearted an d make the audience laugh. Pacing You probably speak quicker than you think; take your time, pause and allow the audie nce to read all your points. Questions Decide in advance if you would like questions to be asked during your presentatio n or at the end. Anticipate what questions may be asked and prepare for these. Do not be af raid to say you do not know the answer, though off er to fi nd out. Feedback Whenever possible ask for constructive criticism from someone who saw your present ation and try to learn from their comments. Consider using the presentation for a formal D eveloping the clinical teacher assessment (b p9). Summary of points for a good presentation \200 Plan well in advance \200 Keep slides si mple, avoid unnecessary graphics \200 Rehearse your talk \200 Try to stay calm and spea k clearly \200 Look at the audience, not the screen \200 Thank the audience for attendi ng. OHFP.indb 62 OHFP.indb 62 30/05/2014 16:17 30/05/2014 16:17 63 TEACHING MEDICAL STUDENTS Teaching medical students Teaching will benefi t you as much as the recipient; it will chal lenge you to fi ll any gaps in your knowledge and organize your thinking on the subject. Yo u may not feel that you know enough to teach medical stu- dents but you are probably the be st teacher on the ward for them, for two reasons: \200 You have recently passed the fi na ls exam that they are trying pass, often at the same medical school Finals are meant to test core medical knowledge; this is what you do every day when you clerk and manage a patient. Portfolio Keep a record of teaching sessions, ideally with feedback (consider using a simpl e online survey tool). At least once a year you will need to complete a Developing the cli nical teacher form assessment (b p9). Teaching principles Whatever information you are trying to convey it is important to follow a few simple guidelines: \200 Be clear about your objectives \200 Plan what you are go ing to teach to give it structure \200 Be interactive; this means that the students do so me of the work and also are more likely to remember it \200 Try not to use too much medical jargon \200 Gi ve relevant examples \200 Check the students understanding throughout and invite questio ns. Suitable patients One of the worst parts of being a medical student is fi nding suitabl e patients to take a history from or examine. You can use your patient lists (b p17) and fi rst-hand experience of the patients to guide medical stu- dents to conscious, orientated, and friendly folk or those with clinical signs. Better still, off er to introduce the stude nt. Clinical examination Off er to watch the student examine a patient and give feedback on the ir technique. You are likely to examine more patients in your fi rst month as a doctor than in all your years as a medical student so your clinical skills will have advanced very qui ckly. FP applications With all the recent changes to medical training many students feel bewil- d ered about what lies ahead. Once again you are in the ideal position to advise since you ha ve already successfully applied for the FP. Simple advice about which are the best jobs, ho w to fi ll in the application form, or even showing a copy of your own form can be a great help. Clinical approach You can also teach \200\230how to be a doctor \200\231 type skills that are rarely passed on. The trick is to choose a simple subject you know lots about, eg: \200 Managing chest pain/breathlessness \200 Fluid management and volume assessment \200 Writing in notes. _OHFP.indb 63 _OHFP.indb 63 30/05/2014 16:17 30/05/2014 16:17 64 CHAPTER 1 Being a doctor Research and academia Research Whatever direction you see your future career heading in, th e opportunity to undertake a period of research will help you gain insight into this vital area that underpins all of medical practice as well as to develop the skills necessary to u nderstand research output. You don \200\231t need to cure cancer \200\223 often the most s uccessful projects are those that set out to answer a simple, well formulated question. Academia is not turning your back on clinical medicine, but rather adding a new dimension t o your clinical experience: most academic doctors do research alongside clinical work. Ther e are many advantages (interest, worldwide conferences, really understanding your subject, making a diff erence) but pay is not one of them. There are various training routes for aca demics detailed as follows \200\223 there is no one single way in; if at any stage you wan t to do research or a PhD there are always opportunities if you look and ask. Foundation years There are small numbers of 2yr academic Foundation Programs (b p5). These are often a normal F1 year with a 4mth academic attachment in F2 (eg academic rheumatology) ; a few have academic components scattered throughout F2 F1. ST years There are also academic ST positions called Academic Clinical Fellowships. Most of these are available for entry either at ST1 or ST3 level and are 2 \200\2233yr long, inclu ding clinical rotations alongside 25% of working time set aside for academia. The fi rst ye ar will be almost entirely clinical; the purpose of the second and third years is to give y ou the opportunity to design a PhD/MD research project, generate pre- liminary data and app ly for funding. Once you successfully get funding you enter the Training Fellowship. Training fellowship This is a 3yr research project designed by your- self with the aim of g etting a PhD (or alternatively a 1 \200\2232yr MD) with small amounts of protected clinical time to maintain your skills. Clinical lectureship With a PhD/MD under your belt you can apply for a 3 \200\2234yr lectur eship post. This will give you clinical experience whilst training to consultant level, and allow you to pursue postdoctoral research interests. You will again need to apply for fund ing, eg a Clinician Scientist Fellowship. Once you have completed this post you will be eli - gible for consultant or senior lecturer positions. Finding a project Although some academic posts will come with funding already tied to a spe cifi c laboratory or project, the most rewarding projects are often those that you design y ourself, together with a senior academic mentor. It is important to speak to a range of peo ple and read and discuss broadly. Keep three things in mind: (1) Do I get on with the super visor and have other clinicians had good experiences in the group? (2) Does the project int erest me? (3) Where will the project lead? (eg will you be able to apply for the career or subspecialty that you want?). Funding One of the challenges of academic medicine is that you often need to raise funding to pay for yourself and your research. The process can take time (eg >6mth) and involves fi lling in multiple forms. Always talk to your potential supervisor for advice on best optio ns. OHFP.indb 64 OHFP.indb 64 30/05/2014 16:17 30/05/2014 16:17 Chapter 2 Life on the wards 65 The medical team 66 The multidisciplinary team 68 Daily ward duties 69 Ward rounds 70 Being on-call 72 Night shifts 73 Writing in the notes 74 Common symbols in the notes 76 Anatomic al terms and planes 77 Forms Discharge summaries (TTOs/TTAs) 78 Fitness to work notes 80 Referrals 81 Referral let ters 82 Investigation requests 84 Radiology 85 Common ward dilemmas Pain 86 Thinking about death 90 Palliative care 91 The dying patient 9 2 Death 94 Nutrition 102 Nutritional requirements 103 Diffi cult patients 104 Aggression an d violence 105 Needle-stick injuries 106 Surgery Pre-op assessment 107 Bowel preparation 109 Surgical terminology 110 Preparing in-p atients for surgery 111 Booking theater lists 112 Surgical instruments 113 The operating th eater 114 Post-op care 116 Post-op problems 117 Wound management 118 Common elective operat ions 119 Stomas 121 _OHFP.indb 65 _OHFP.indb 65 30/05/2014 16:17 30/05/2014 16:17 66 CHAPTER 2 Life on the wards The medical team The changes to medical training have caused widespread confusion about the names and roles of diff erent trainees. The medical team or \200\230fi rm \200\231 usuall y consists of four grades: (1) consultant-level, (2) registrar-level, (3) SHO- level, (4) F 1 (house offi cer). Many fi rms have more than one doctor at each level so you may work alo ngside other F1s under two or more consultants. Consultant-level These are the most senior doctors on the team; there are several posts at this level: \200 Academic Doctors who split their time between research and clinical medi cine. They are often called \200\230honorary consultants \200\231 alongside an academic gr ade (eg senior lecturer, reader, professor) Consultant The most common post at this level is reached by obtaining the CCT (b p43), formerly known as the CCST, or via proof of equivalent training known as the CESR. Associate specialist A doctor with consultant-level ability and experience who has not got a CCST/CCT/CESR. They do not have the accountability or manageme nt commitments of consultants. Consultant role Consultants are responsible for everything that happens on the ward includi ng the actions of junior doctors. They may lead ward rounds, work in clinics, supervise a l aboratory, or spend time in theater; their level of involvement in the day-to-day running o f the ward varies between specialties and management styles. They will perform your FP appr aisals (b p25) and are a good source of advice for careers, audits, and presentations. If e ver you need help and only the consultant is available then do not hesitate to contact them . Registrar-level If you describe yourself as \200\230a registrar \200\231 most people will assume that you are at this grade. All of these doctors will share an on-call rota that is usually separate from the SHO-level on-call rota. The posts have a natural hierarchy accord ing to experience: \200 Specialist registrar (SpR) Doctors training under the old system; virtually none of these remain, but you will still hear the term \200 Staff grade/specia lty doctor A non-training post with equivalent experience to an SpR but not working towards a CCT award Clinical fellow A specialty doctor who is undertaking research; they may need to secure an ST3/4 post afterwards Clinical lectureship The academic equivalent of \211 ST3/4 they will split their time between clinical and research Senior specialty training registrar (StR, \211 ST3/4) In most specialties this grade starts at ST3; however it is ST4 in emergency medicine, pediatrics, and psychiat ry. These are posts that work towards the CCT award and a consultant post. Registrar role These doctors supervise the day-to-day running of the ward; they perform sim ilar jobs to consultants (ward rounds, clinics, theater) but without the management respons ibilities. Registrars usually receive referrals from other teams and will spend time review ing these patients. Their presence on the ward varies between specialties. OHFP.indb 66 OHFP.indb 66 30/05/2014 16:17 30/05/2014 16:17 67 THE MEDICAL TEAM SHO-level Like the registrar-level position there are a range of posts performing similar r oles with a hierarchy of experience: \200 Academic clinical fellow (ACF) The academic equ ivalent of ST1 \200\2232/3 and CT1 \200\2232/3 at this level they will perform a similar ro le except that they have 25% of their time set aside for research. The situation can be con fused in certain posts where the ACFs are appointed at ST3 level \200 Junior specialty tr aining registrar (StR, ST1 \200\2232/3) Doctors in specialties with run-through training (b p43) who will progress to registrar-level specialist training unless they fail to attain competencies or exams. Despite the title it is misleading to cal l them \200\230a registrar \200\231 Core-training (CT1 \200\2232/3) Doctors in specialties with uncoupled training (b p43) who can apply for registrar-level specialist training posts if they attain the relevant compete ncies and exams. The diff erence between ST and CT posts is the specialty, not experience Fixed-term specialty training appointment (FTSTA) A post for doctors who were unwilling or unable to secure an ST/CT post. The post lasts 1 year and will be at ST1, ST2, or ST3 level ; at the end of the year they can apply for an ST or FTSTA post at the next level if they h ave attained the relevant competencies F2 doctors in the second year of the Foundation Program; this will often be their fi rst ex perience in the specialty and at SHO level. At the end of the year they will apply for ST/C T/FTSTA posts. SHO role These doctors are your fi rst port of call for help. They can advise on patient ma nagement, ward jobs, and supervise practical pro- cedures; they often work alongside F1s on the ward though they may have clinic and theater commitments too. They are an excellent so urce of advice on careers, applications, exams, and training courses. F1-level These are doctors in their fi rst year with limited registration. They are still o ften called house offi cers or PRHOs from the old system. F1 role F1s manage the day-to-day running of the ward including ward rounds, ward jobs, pro cedures, and reviewing unwell patients; see b p69 for more detail. _OHFP.indb 67 _OHFP.indb 67 30/05/2014 16:17 30/05/2014 16:17 68 CHAPTER 2 Life on the wards The multidisciplinary team Nurses have a \200\230hands-on \200\231 role, ranging from admi nistering medications to attending doctors \200\231 rounds. Don \200\231t be afraid to ask their advice \200\223 their experience means they can often help you out. Most can take bl ood and perform ECGs, some can cannulate and insert male urinary cath- eters (all female nu rses should be able to insert female catheters). Bed managers are highly stressed people wh o are in charge of man- aging the hospital beds and arranging transfers and admissions. The y will frequently ask you when patients are likely to be ready for discharge so they can pl an ahead for routine admissions. Discharge coordinators work in conjunction with social wor kers, physiotherapists, and occupational therapists to expedite patients \200\231 dis- char ges. They often assist in fi nding intermediate care placements. Healthcare assistants (HCA s) perform more basic nursing tasks eg help with personal care and recording observations i ncluding fi nger- prick glucose. They cannot dispense medication or give injections, but ma ny can take blood. Nurse practitioners are specially trained senior nurses who can assess a cutely unwell patients, perform practical procedures (eg cannu- lation), and assist in thea ter. Most cannot prescribe, although there are some who are qualifi ed to use the nurses \200\231 formulary. Nurse specialists include stoma, respiratory, pain, cardiac, diabetes, tissue viability, and Macmillan nurses. They are excellent for giving advice and are an imp ortant fi rst port of call for the junior doctor. Occupational therapists work with patient s to restore, develop, or maintain practical skills such as personal care. Assess patient home for adaptations required to help with activities. Many elderly patients require OT a ssessment before discharge \200\223 nurses usually make the referral. OTs work in primary and secondary care. Pharmacists dispense drugs and advise you on medication. They check the accuracy of every prescription that is written. Most hospitals have a drugs information-li ne which you can call for prescribing advice. Phlebotomists are professional vampires who a ppear on the wards with the specifi c aim of taking blood. They often appear at unpredictab le times and they may not come at all at weekends, so leave your blood forms out well in ad vance. Some can take blood from central lines and perform blood cultures. Physiotherapists use physical exercises and manipulation to treat injuries and relieve pain. Chest physios a re commonly found on respira- tory and surgical wards to help improve respiratory function and sputum expectoration by teaching specifi c breathing exercises. Involve them early in p atient management \200\223 nurses usually make the referral, but do not hesi- tate to disc uss your patient \200\231s needs or progress directly with them. Social workers support pat ients \200\231 needs in the community. They assess patients and help organize care packages (invaluable for elderly patients). Where residential care is required they help guide fami ly and patient through the decision-making process and fi nancial issues. They are also inv olved in child protection and vulnerable adult safeguarding work. OHFP.indb 68 OHFP.indb 68 30/05/2014 16:17 30/05/2014 16:17 69 DAILY WARD DUTIES Daily ward duties First thing \200 Handover from night team about any overnight events \200 Submit any mi ssing or extra blood/CXR/ECG requests \200 Review new patients, consider writing a brief summary. Ward round \200 See b p70 for ward round duties, try to keep a jobs list \200 Attempt to start simple jobs (eg TTOs) during ward round. After the ward round \200 Spend a few minutes comparing and allocating jobs with the other team members; try to group jobs by location and urgency Radiology requests (USS, CT, MRI) \200 Referrals to other teams, eg surgery/cardiology/ps ychiatry \200 Complete TTOs and other forms \200 Take blood from patients whom the phle botomists have been unable to bleed or that have been requested during the ward round. Lunch \200 Do you need to do anything for yourself, eg book holidays, pay bills? \200 Y ou may have teaching/grand round/journal clubs. After lunch \200 Review patients you are worried about. Liaise with nurses re any problems they have identifi ed and attend to routine tasks they may have Check and record blood results; serial results sheets help \200 Check other results; chas e outstanding requests or results \200 Spend time talking to patients relatives \200 Submit blood and other investigation requests for the next day \200 Check the patients \200\231 drug cards \200\223 do any need rewriting? Before you go home \200 Review resul ts and outstanding jobs with other team members; make a note of anything that needs doing the next day Check that all warfarin and insulin doses have been written up \200 Prescribe suffi cient IV fl uids for patients overnight where safe to do so \200 Handover patients who are sic k or need results chasing to the on-call doctor (b p72); write down their ward, name, DoB a nd hospital number and exactly what you want the doctor to do (ie not just \200\230check b loods \200\231). Before weekends \200 Only submit blood requests for patients who really need them \200 Try to prescribe 3 days of warfarin doses where safe to do so \200 Make sure that no drug cards will run out over the next 2 days, rewrite them if they will (this is infuriating to do as an on-call job) Ensure notes contain a brief and easy to fi nd summary of each patient for the on-call team (especially for those who are unwell); include presenting comp laint, relevant investigations, and plan for the weekend. _OHFP.indb 69 _OHFP.indb 69 30/05/2014 16:17 30/05/2014 16:17 70 CHAPTER 2 Life on the wards Ward rounds A smooth ward round requires preparation of notes, investigations, and results. Try to predict requests and start the ward round armed with the appropriate answers. See F ig. 2.1 for guidance on recording rounds in patient notes. Before the ward round \200 Upd ate the patient list with patient details, location, summary of clinical problems, key investigations/results, referrals made, and jobs \200 Ask the nurs es if any patients have changed condition overnight and try to avoid any nasty surprises on the round; briefl y review individual patients where ap propriate Check notes, drug cards, obs charts, X-rays, and blood results are present \200 Clearly d ocument all relevant investigation results and reports in the notes with a brief summary on your patient list Check all notes have continuation sheets headed with the patient \200\231s name, DoB, and h ospital number/address (use a hospital sticker) Consider writing out the patient \200\231s problem list/summary \200 If your patients hav e moved, fi nd out where they have been transferred to and plot an effi cient route through the hospital to visit all your outlying patients Check or chase the dates/times for outstanding investigations \200 Learn your consultant \200\231s favorite questions from your predecessor (eg patient occupation) Consider multidisciplinary issues which may alter further management or delay discharge for the patient (eg home circumstances) Think about management dilemmas you want/need answers to. During the ward round \200 Ask a nurse to join you on the ward round \200 If there are two junior doctors then one can p repare the notes, obs, drug cards, and X-rays for the next patient whilst the other present s \200 When presenting a patient, always begin in the same logical way, eg \200\230Mrs S mith is a 64-year-old lady who presented with a 4-day history of worsening shortness of bre ath \200\231 then proceed to past medical history, investigation, and blood results, then y our management plan If you have a spare moment start fi lling in forms or doing the jobs generated on the ward round (eg prescribing fl uids) If you have any queries about the next step of management or investigation results, ask dur ing the ward round. Also ask about rationale for imaging if unsure as this makes requesting imaging easier for you (b p85)! 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; never make up results. After the ward round \200 Sit down with the rest of the team and g o through the jobs generated from the ward round over a cup of tea Prioritize the jobs and group by location, eg outlying wards, radiology \200 Allocate the jobs between your team as appropriate \200 If you are unsure of how to approach any of t he jobs, ask your seniors \200 Clarify any gaps in your understanding of the patients \200\231 management. OHFP.indb 70 OHFP.indb 70 30/05/2014 16:17 30/05/2014 16:17 71 WARD ROUNDS Mr Johnston/Miss Jain \200\231s patient list 16/09/14 Investigation/Detail Jobs Patients, Details Problem list Sample patient list Sample ward round entry Fig. 2.1 Sample of a ward round entry in the patient \200\231s notes. _OHFP.indb 71 _OHFP.indb 71 30/05/2014 16:17 30/05/2014 16:17 72 CHAPTER 2 Life on the wards Being on-call Being \200\230on-call \200\231 will occupy a large amount of your time and m ay involve care of a diff erent group of patients and a greater range of specialties than d uring the day. Requirements, expectations and priorities are diff erent. What \200\231s important \200 Ensure you have a clear handover about which patients are w aiting to be seen, how urgently they need seeing, and where they are \200 Know who you are on call with and how best to contact them \200 Identify the sick and get help early \200 Priori tize eff ectively and stay organized \200 Eat and stay well hydrated \200\223 there is a lways time for a cup of water and you will be much less effi cient if you don t look after yourself. How to handle the bleep when tired \200 Always try to answer promptly; when you don \200 \231t it will be the boss or someone really unwell Write down who called and the job required \200 Learn common extension numbers so you can spot the call from switchboard, the mess, or your consultant \200\231s offi ce. Being organized on-call \200 Document every task, otherwise you will forget something \200\223 do not use scraps of paper; use a notepad or PDA Have a means of identifying when you \200\231ve done it (drawing a box to tick when complete helps) Visit all the areas you cover in order and tell the wards this is what you \200\231ll be do ing; ask them to compile a list of non-urgent tasks for when you arrive When you order a test on-call, make a note to check the result as it \200\231s easy to forget. Prioritizing \200 Sick patients need seeing fi rst; if you have more than one really sick patient then tell your senior If the patient \200\231s condition is clearly life threatening then consider asking the ward to bleep your senior while you \200\231re on your way there Check if a task has a deadline (eg before drugstore closes) \200 If you see an abnormal b lood result check the patient/notes/ previous blood results (see b p566 \200\223571) Ask if a task can wait until you \200\231re next in that area; tell the staff when this will be and try to stick to it. Taking breaks You are entitled to a 30min paid break for every 4h work. Whilst you must not ignore a sick patient, there will be a constant supply of work that can usually wait. Brea ks are not just about food, they keep you alert and reduce stress and tension headaches. It is in your patients \200\231 interests that you recharge. Drink plenty of water. Where pos sible, arrange to take breaks with the other members of the team on-call \200\223 it allow s you to catch up and stops you feeling isolated. OHFP.indb 72 OHFP.indb 72 30/05/2014 16:17 30/05/2014 16:17 73 NIGHT SHIFTS Night shifts Few doctors look forward to their night shifts, especially if they are doing s everal in a row. That said, on nights you will gain a lot of experience. Things to take with you \200 Food, both a main meal and several quick snacks \200 Tooth brush, toothpaste, comb/hairbrush, and deodorant \200 Stuff for gaps in workload \200 \223 eg books for private study. Things to check (on the \201 rst night) \200 What area s and specialties are you responsible for? \200 Who are your seniors and what are their b leep/mobile numbers? \200 When and where is handover? What is expected of you \200 Turn up on time; your colleague will be late home if you don \200\231t \200 Prioritize work a ccording to urgency \200\223 when bleeped to a sick patient ask for obs ECG to be done while you get there Tour the wards you are covering regularly and delegate simple tasks \200 Document all int erventions in the notes. Hospital at night (H@N) This system is now in place in many hospit als to improve effi ciency and the standard of care provided by the limited number of docto rs on duty at night. Generally all bleeps should go via the Night Sister, who then fi lters them appropriately, eg assessing which jobs could be done by a nurse (eg cannula) and whic h patients need urgent review by a doctor. Learning at night Nights can be a good learning opportunity. Ensure the other doctors on at night know if you have particular skills you wish to learn at that time (eg lumbar punctur es). They can then call you to observe or be supervised. Pitfalls The potential to make mistakes during night shifts is greater than during the day. If you are unsure, check. The following are some of the common problem areas: \200 Poor handover; ensure you know who needs review (b p20) \200 Failing to appreciate a sick pati ent and not calling for help \200 Fluid prescriptions (eg failing to note renal/heart fai lure, DM, electrolyte imbalance) Warfarin prescriptions with INRs coming back out of hours. How to cope when not at work \200 Try to sleep (or at least lie down) for a few hours during the day before your fi rst night shift Go to bed for at least 7h each day, even if you don \200\231t sleep you \200\231ll rest \200 Make your room dark and quiet \200\223 eye masks/earplugs help; ensure anyone else in the house knows you are working nights Eat enough; have a meal when you get up and before going in \200 Travel home safely; if y ou feel too tired take a 20 \200\22330min nap fi rst. _OHFP.indb 73 _OHFP.indb 73 30/05/2014 16:17 30/05/2014 16:17 74 CHAPTER 2 Life on the wards Writing in the notes See Fig. 2.2. Most new F1s are unsure about writing in medical notes s ince this is rarely practiced as a medical student. There are a few rules which everyone, i rrespective of grade, should conform to (Fig. 2.2): Notepaper The patient \200\231s name, D oB, 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 \200\230WR ST2 (Smith) \200\231 or \200\230Discussion with patient and family \200\231. Sign every entry and print your last name and bleep number clearly. What t o write Document the condition of the patient, relevant changes to the history, obs, examin ation fi ndings, the results of any new investigations, and end with a clear plan. The note s should contain enough information so that in your absence someone else can learn what has happened and what is planned for the patient. Always allow yourself plenty of space when w riting in the notes, especially if docu- menting a ward round \200\223 your seniors may me ntion a point of the plan early on (which needs to go at the end of the entry) but then per form a detailed examination which you should document in the space you have left. Try to do cument everything that is discussed or observed \200\223 it is extremely frustrating for a senior to ask a series of detailed questions with medicolegal implications and then to fi nd nothing documented. Problem lists It is helpful to write a problem list in the notes eit her every day if there are frequent changes (eg new admissions or in ICU/HDU), or less freq uently for chronic conditions. This should include both medical and social problems. Having problem lists also makes it easier for on-call doctors to understand the patient \200\231s condition if they are asked to review them, as well as refreshing your memory at the start of the next ward round. See Fig. 2.3. What not to write Patients can apply to read their m edical 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 acce pted (eg obese lady) but not subjective material (eg annoying time-waster). Never doodle in the notes and do not write humorous comments. How to write Write clearly in black; poorly legible notes result in errors and are indefensible in court. Use only well recognized abbr evia- tions and don \200\231t worry about length as long as suffi cient information is docu mented. Always write in the notes at the time of the consultation, even if it means asking the ward round to wait a few moments. Making changes If you wish to cross something out sim ply put a single line through the error and initial the mistake. Never cross it out so it c annot be read as this looks suspicious. Previous entries should not be altered, instead mak e a new entry indicating the change or diff erence. Notes and the law It is unlikely that y our notes will be used in court. If they are, you want them to show you as a caring and cle ar-thinking individual; make that clear from how you write. As far as a court is con- cerne d, if it \200\231s not documented then it didn \200\231t happen. Hints and tips Bullet poin ts are a useful and clear means of documen- tation. It is acceptable to write about a patie nt \200\231s mood and it is useful to document if you have cheered them up or discussed som e bad news (b p22). It is also acceptable to document \200\230no change \200\231 if this i s the case. OHFP.indb 74 OHFP.indb 74 30/05/2014 16:17 30/05/2014 16:17 75 WRITING IN THE NOTES 16.9.14 10:20 WR ST4 (Ackerman) Problem: Admitted last night with central chest pain ?ACS Progress: Pt co mfortable. No further chest pain. P70 reg, BP 132/81, RR 15, Sats 99% on room air. CXR show s bilateral pleural effusions (Wrong patient CJF) Rpt ECG \223\203, no new changes. Imp \200 Atypical chest pain, unlikely to be cardiac. \223\205 \200 Await cardiac markers \200\224if \223\203, \222 c \200\223 no f/u. \200 Pt wants to discuss risk factors when family arrive. Dr C J Flint F1 Bleep 3294 16.9.14 11:12 d/w with pt and wife Pt wanted to talk about cardiac risk factors. Given British Heart Foun dation lea \202 et on risk factors and talked about lifestyle changes. Cardiac nurse will see pt before discharge. Rpt cardiac markers \223\203. Pt much relieved. \222 later. Dr C J Flint F1 Bleep 3294 16.9.14 15:34 Review, F1 (Flint) No change. TTO completed. \222 . Dr C J Flint F1 Bleep 3294 Fig. 2.2 Example of entries in medical notes. 16/9/14 09:00 Mrs Jones \200\231 current problems: 1 Left lower lobe pneumonia \200\223 on day 2 IV co-a moxiclav 2 Atrial \201 brillation (Z009) \200\223 on digoxin and warfarin 3 Hypertension \200\223 well controlled on ramipril 4 Previous CVA (2009) with right sided weakness 5 Pr evious left knee replacement (2002) 6 Not able to manage at home \200\223 needs increased package of care prior to D/C Fig. 2.3 Example of a problem list. _OHFP.indb 75 _OHFP.indb 75 30/05/2014 16:17 30/05/2014 16:17 76 CHAPTER 2 Life on the wards Common symbols in the notes Home Normal Plan Left Right Temperature Diff erential diagnosis Diagnosis Impression Prescr iption or drugs Symptoms Treatment Investigations On examination Negative Positive Equivoca l Presence noted Present signifi cantly Present in excess History of Discussed with or disc ussion with Ward round Review Follow-up Asked to see patient In-patient Out-patient Complai ns of or complaining of Patient With At Eating and drinking Nausea and vomiting Diarrhea an d vomiting Bowels open Passing urine Bloods No/negative (as in previous MI) Primary Secon dary Tomorrow morning Nursing Staff \222 \223\203 \223\205 \223\201 \223\207 \223\211 dd/DD/DD/ZZ x/Dx/Z Imp Rx Sx Tx Ix O/E \200\223ve +ve +/ \200\223 + ++ +++ h/o d/w WR r/v f/u ATSP IP OP c/o Pt c \200\223 @ E+D N+V D+V BO PUing blds 1 2 mane N/S OHFP.indb 76 OHFP.indb 76 30/05/2014 16:17 30/05/2014 16:17 77 ANATOMICAL TERMS AND PLANES Anatomical terms and planes The anatomical position Anatomical planes Coronal or frontal plane Sagittal plane Axial, transverse or horizontal plane Fig. 2.4 The anatomical position and anatomical planes. Commonly used anatomical terms and their meanings Anterior/ventral Contralateral Coronal/frontal plane Distal Inferior/caudal Ipsilateral Lat eral Medial Palmar Plantar Posterior/dorsal Prone Proximal Radial Front of the body On the opposite side Divides anterior from posterior Away from the trunk Away from the head On the same side Away from the midline Towards the midline Pertaining to the palm of the hand Pertaining to the sole of the foot Back of the body Face down positio n Close to the trunk The lateral (thumb) aspect of the forearm Divides left side from right side Towards the head Face up position Sagittal plane Superior/cephalic Supine Transverse/horizontal/axial plane Divides upper and lower sections Ulnar The medial (little fi nger) aspect of the forearm _OHFP.indb 77 _OHFP.indb 77 30/05/2014 16:17 30/05/2014 16:17 78 CHAPTER 2 Life on the wards Discharge summaries (TTOs/TTAs) \200\230TTOs \200\231 or \200\230TTAs \200\231 (to take o ut or away) are summaries of the patient \200\231s admission from the ward doctors sent to the patient \200\231s GP and are often the most complete summary written. TTOs are written on a computer (very occasionally by hand with carbon copies); you should receive training o n the local system as part of induction. They form a point of reference at future clinic vi sits or admissions. They also provide clinical coding informa- p tion with which the hospit al bills primary care for care provided. p y p TTOs should contain the following information \200 Patient details: name, DoB, hospital n umber, address \200 Consultant and hospital ward \200 Presenting complaint, clinical fi ndings, and diagnosis \200 Investigations/procedures/operations/treatment, including any complications Treatment on discharge and instructions to the GP, including medications stopped and reasons why Follow-up arrangements \200 Your name, position, and bleep number. When to write TTOs TTOs should be written as soon as you know the patient is likely to be d ischarged. This allows the drugs to be dispensed from drugstore as soon as possible so that the patient \200\231s discharge is not delayed. See Fig. 2.5. \200 Begin to enter inform ation on the TTO at the earliest opportunity; check any queries with your team, particularl y regarding the principal diagnosis \200 Check the duration of the medication for dischar ge (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 you r hospital \200\231s drug information-line Check required follow-up appointments, give details and be clear on who will arrange them(e g the ward clerk or the clinic administrators) \200 Phone the GP if the patient needs an early check-up, has a poor social situation, or self-discharges. It may take several days f or a TTO to reach the GP: written instructions such as check K+ in 3/7 are unsafe \200 Hand the TTO and the patient \200\231s drug chart to the patient \200\231s nurse or inform them that you have completed it to avoid unnecessary bleeps \200 If you are unsure whethe r the TTO has been done check the drug chart; there is often a tick in a box showing if TTOs have been dispensed Discuss the diagnosis, results, and discharge plan with your patient; if they understand th e management plan they are more likely to comply. Controlled drugs for TTOs These are slightly more complex, but can still be written by F1 d octors in most trusts. They must include all the information in Table 2.1. CD pre- scriptio ns are only valid for 28d from the date of signing and only 30d of g p CDs can be dispensed on a single prescription. See also Fig. 2.6. p p g