“I feel like a spare part”BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1761 (Published 11 August 2021) Cite this as: BMJ 2021;374:n1761
- Hannah Beresford, fourth year medical student, Cardiff University
The majority of work for the ward round occurs in the preparation.
What to do before attending a ward round
Always be 10 minutes early. There is nothing worse than trying to find a ward round that has started without you.
Ensure you have the bleep number for the F1 or on-call doctor in advance. This will stop you from having to chase a team around the hospital if they’ve changed location.
Know the doctors’ names. Be confident and introduce yourself.
Read up on the common conditions you are likely to see on the ward. Some basic knowledge will go a long way and will allow you to ask helpful questions.
Ask for a copy of the printed patient list. This is such a simple yet crucial way of being in the loop with each patient and having a good understanding of the ward round.
Take a notepad and pen.
Wear comfortable shoes—you will be standing.
Familiarise yourself with some of the patients the day before by asking to take histories from suitable patients. Not only will the patients feel more comfortable with you, but you will be able to present these patients to the consultant on the ward round.
Ensure you are familiar with how the hospital records and stores its test results, such as blood results and scans. You will be able to present these results to the doctor for each patient and will be more useful to the team as you move around the ward.
A ward round that you are well prepared for is an excellent opportunity to practise examinations and to see common conditions first-hand. The more you actively engage, the more you will get in return.
How to get to grips with a busy ward
Most wards will have all of their information about their current patients and beds on a board. This may be on a computer screen or a whiteboard, but all of the information you need about any patient will be located here. Know where the board is and how it relates to the beds on the ward.
Learn where the important things are kept. As a medical student, you need to be proactive in your learning opportunities, and offering to take blood or place a cannula is a lot easier when you know where the equipment is. The same goes for continuation sheets, drug charts, and forms.
Find where the patient notes are kept and find the ward round trolley. Some wards work in different ways, so it will be helpful to familiarise yourself with how your specific ward stores its information.
Introduce yourself to all members of staff, not just the doctors. The ward is run by the multidisciplinary team, and everyone plays a vital role in patient care. Take the time to chat to the nursing staff, ward manager, and allied healthcare professionals such as physiotherapists, pharmacists, occupational therapists, and others.
Note taking—If you don’t write it down, it didn’t happen
Note taking on a ward round is what provides the tangible evidence of the clinical decisions that have been made that day and allows for continuation of care for the next set of staff members. It also happens to be an excellent opportunity for medical students to prove useful, providing a good experience of the tasks you will perform as an F1 doctor.
Here are some basic rules that will prepare you for taking clinical notes.
Watch the F1 doctor take notes first. These will guide you in what the salient information is and how to set out your documentation.
Prepare the notes for the patient before you see them. This is common practice for F1 doctors and is a good habit to get into. Ensure that, before you get to a patient, you have looked through the notes and written the following: (a) a brief “one line” sentence regarding their reason for admission, and (b) their top three clinical problems. These are often found by reading through previous entries.
Begin with a patient sticker. Every single page in the paper patient notes needs to include a patient sticker. These can be found in the front of the clinical notes, or ask a friendly nurse to print them out for you. It is a legal requirement to do this, and so is an excellent habit to get into early.
Start every entry with the consultant’s name, the date and time, and your role.
Find the National Early Warning Score (NEWS) chart. Every interaction with a patient should involve documenting their most recent NEWS score.
Write down the most recent, relevant blood results. This is the important information that future clinicians will want to be able to see at a glance. For example, if the patient has come in with an infection, noting down the previous and most recent CRP is helpful for the clinician to see the trend in results.
Jot down the patient’s current list of “clinical problems.” For example, on an elderly care ward this might include “catheter in situ, UTI and delirium,” whereas on a surgical ward it might be what operation a patient had and the number of days post-op.
Once your notes are prepared, it is time to see the patient. This will usually involve the team talking to the patient and conducting examinations based on the clinical presentation. It is important that, as the team member taking notes, you know how to write down the key points.
Begin with a section title, usually “On examination.”
One line is needed to summarise the general wellbeing of the patient—such as “the patient is comfortable at rest” or the “patient is awake and chatting to the team.” This allows clinicians to immediately know the status of the patient.
In terms of clinical examination, there will most likely be a brief top-to-toe examination undertaken. It is important that you learn a methodical way of noting down the findings that are universally understood. This will usually include a respiratory examination, a cardiovascular examination, a brief neurological examination, assessment of the abdomen, and assessment of the legs.
Learn the shorthand: I cannot stress enough how important this is. Key phrases such as “PRN” (as required), “QDS” (four times daily), “NBM” (nil by mouth), etc (see https://www.qegateshead.nhs.uk/sites/default/files/users/user1/Approved_abbreviations_for_use_in_Clinical_Records_and_letters.pdf).
Learn how to draw clinical diagrams to summarise your examination findings (fig 1). Research what they mean and how to draw them, as they are common across most specialties.
Each set of clinical notes will then conclude with a “plan”—three or four things to be done (such as “request a CT scan” or “complete the discharge summary”). Finish every entry with your name, your signature, and your role as a medical student, and ensure that it is co-signed by a healthcare professional.
Golden tips for students on a ward round
Stick with your F1 and try to be as engaging as possible with every learning opportunity. Offer to help complete the jobs on their list.
Always look at the patient’s drug chart. Learn what each of the drugs do and familiarise yourself with the doses. This is excellent practice for progress tests and will stand you in good stead for the PSA (prescribing safety assessments).
Always make sure you have a copy of the patient list.
Luca Galbani, FY1 at the Royal Glamorgan Hospital
Becoming adept at the ward round not only enhances your learning experience, but it prepares you directly for your F1 responsibilities. It is the bridge between medical school and the realities of being a junior doctor.
Competing interests: None declared.