Tag: notes

Documentation, prioritisation, and handover

Documentation, prioritisation, and handover

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