Documentation By 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?

 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

FY 2 Latham ED SHO Signed

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

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.