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DocumentationBy Peter Latham
FY2 A&E
What we’re going to discuss
The basics
Clinical Summary, ward rounds, TTOs
Post Death Certification TTO
Talking and documenting conversations with other specialties
Don’t be this Guy
Why be a Master of Documentation?
Massive help to other specialties reviewing the patient, or on call doctors.
Why be a Master of Documentation?
Why be a Master of Documentation?
Why be a Master of Documentation?
Massive help to other specialties reviewing the patient, or on call doctors.
An accurate recording of the patient story
Map their journey through the hospital
Help identify where things began to improve or decline
Legally – it can save your bacon!!
Pitfalls of Poor Documentation
Lack of Preparation
Teamwork – rarely will you be the only junior on the wardround
Pre-wardround prep – blood stickers, look up NEWs, print scan reports
Surgeons
Medical wardrounds start later and have a more gentle pace
Surgical wardrounds are 100mph
Don’t feel bad asking to repeat things, asking them to hold on, did they find anything on examination, repeat the plan, show them the drug Kardex
Targets to think about during the Wardround
Positive Outcomes
Leaving before 6pm
Having a lunch break
Having a coffee break
Not looking incompetent
Gaining some form of respect from the nursing staff
Being able to sit down at some point
Targets to think about during the Wardround
Things that stand in the way of this:
Cannulas – ask if we still need IVI, can we switch Abx to oral, are we happy with that UO,
NEWS – is that BP OK for the patient, are we concerned about that HR
Meds R/V – show them the Kardex,
Bloods – do we need to do any more bloods on this pt, are you happy with that trend
Referrals – what exactly do we want from the radiologist, surgeons, Med Reg?
Family Questions – whats our Imp, ?home tomorrow
Basics
Basics
FY2 LathamED SHOSigned7420531
Talking to other Specialities
When asked to discuss with another team think about the following things:
What clinical question are we asking them?
Do we want advice?
Do we want them to see the patient?
Do we want them to take over the question?
Stick to the SBAR system, have all the information you need by the phone.
Document the key elements of what was discussed
Make sure you get their name and a contact number
TTOs
Think about it as if you were on the phone, speaking to the GP, telling them all the important events
Also think about the next time the patient presents to A&E, what important things need to be documented for the admitting Doctor
Tell a succinct patient story
TTOs
Diagnosis – Type I Respiratory Failure Secondary to Community Acquired Pneumonia
Mrs Blogs presented to ED with SOB and a productive cough. She was found to hypotensive, tachycardic and drowsy. An ABG revealed a Type I Respiratory Failure and CxR showed Left lower lobe consolidation. She required Iv Abx and NIV. Sputum Cultures grew S.Pneumoniae. With Abx and chest physio her symptoms improved and she is now medically stable for discharge.
Other things to mention – DNARs, thickened fluids, changes to social, recommendations given to patient (DVLA etc)
TTOs
Investigations
Bloods – WCC 22, CRP 208, U&E – NAD
CxR – Left lower lobe pneumonia
ECG – Left Axis Deviation, SR
BCM – S.Pneumoniae (sensitive – Penicillin)
CT Thorax – try and fit whole report
TTOs
Procedures
Chest Drain – what did it grow
Operation – exactly what and was it complicated
Endoscopy? Bronchoscopy
TTOs
Follow-up
- what have you organised – CxR on arrival, Echo
- what needs organising at booking centre (Check)
GP Advise
- very busy people
- document medication changes,
- Recheck bloods
- Refer to clinics that you cant
- Not just monitor symptoms, unsure patient remains well etc
TTOs – The Bad
Diagnosis – chest infection
Pt admitd with cough. Received Abx. Bloods improved, now stable
Pmhx
Smoker
Investigations
Bloods
TTOs
GP
Refer to Resp Clinic
Get Pt to stop smoking
Repeat Bloods next week
Meds
Co-amox
Clarithro
GP to review
Deaths
Sadly you will see a lot of deaths as a junior doctor – it’s a reality of the job
Some jobs you will forever find yourself filling out Death Certificated
ALWAYS, ALWAYS, ALWAYS, ask the consultant SPECIFICALLY what they want as 1a, b, c. I recommend asking them as soon as you find out about the death, and double check whilst in the bereavement office
Do they need to be referred to the coroner
Always double check with the bereavement staff what is acceptable and what is not.
Death - TTO
Diagnosis – 1a Type I Respiratory Failure Secondary
1b Community Acquired Pneumonia
1c –
Mrs Blogs presented to ED with SOB and a productive cough. She was found to hypotensive, tachycardic and drowsy. An ABG revealed a Type I Respiratory Failure and CxR showed Left lower lobe consolidation. She required Iv Abx and NIV. Sputum Cultures grew S.Pneumoniae. Despite these treatments Mrs Blogs deteriorated and sadly passed away on 23/7/2015 at 16.15.
My General Tips
Always, always work together
When you’ve finished your work, help out someone else
Leave on time, TOGETHER
ALWAYS ask for help if you need it. Never be ashamed
Never, ever, pass up an opportunity to poop, pee, eat or drink – you may not get that opportunity again!!
Everyone has the same goal, be respectful, be helpful and it’s nice to be nice.