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.