Foundation doctor roles Flashcards
on ward rounds what are the main responsibilities
Hygiene- before and after patient contact • Note keeping • Updating clinical care • Prescribing • Referrals and commissioning tests • Handover medical-medical medicalnursing • Discharge paperwork Prioritization and delegation Organizing tests and referrals Reviewing results
how do we do adequate note keeping
Date time nature of review • Subjective- what the patient says • Objective- what you observe/examine/test results • Assessment – what you make of it • Plan- what you are doing about it • Signature • HANDWRITING
EVEN RECORDS OF TALKING TO SOMEONE - or it did not happen !
what are the two forms of clinical updates ?
Full presentation vs. 1 minute summary
how to accurately do SBAR handover
Situation: I am (name), (X) nurse on ward (X) I am calling about (patient X) I am calling because I am concerned
that… (e.g. BP is low/high, pulse is XX, temperature is XX, Early Warning Score is XX)
Background: Patient (X) was admitted on (XX date) with… (e.g. MI/chest infection) They have had (X operation/procedure/investigation) Patient (X)’s condition has changed in the last (XX mins) Their last set of obs were (XX) Patient (X)’s normal condition is… (e.g. alert/drowsy/confused, pain free)
Assessment: I think the problem is (XXX) And I have… (e.g. given O2/analgesia, stopped the infusion) OR I am not sure what the problem is but patient (X) is deteriorating OR
I don’t know what’s wrong but I am really worried
Recommendation: I need you to… Come to see the patient
in the next (XX mins) AND Is there anything I need to do in
the mean time? (e.g. stop the fluid/repeat the obs) Ask receiver to repeat key information to ensure understanding
how to discharge a patient ?
FY1s do not normally initiate the decision to discharge a patient
