Transcript How to Perform a Daily Review of Patient

HOW TO PERFORM A DAILY REVIEW
OF PATIENT PROGRESSION
Dr Vicki Ibbett (LTFT FY1)
WHY DO A DAILY REVIEW OF PATIENT’S
PROGRESS?
To optimise patient care…
 Are they clinically improving / stable / deteriorating?
 Are changes to clinical interventions required?
 Are there any other concerns / issues? (e.g. with medications)
…& thus guide your daily jobs
THE BASICS
Ward rounds vary
 Often you’ll be with a senior
… so your job will be providing info & documenting
 But in medical posts you may be alone!
Know who your patients are!
 Make sure you’ve got a patient list (& keep it updated!)
Have a structured approach
 Stick to it so that you don’t forget anything!
WHAT ARE THE KEY THINGS TO COVER IN A DAILY
PATIENT REVIEW?
WHAT ARE THE KEY THINGS TO COVER IN A DAILY
PATIENT REVIEW?
 Reminder of reason for admission +
working diagnosis
Progress & events since last review
 Read the entries in the notes!
 Investigation results
 Trends in blood tests & obs
Current patient concerns
Speak to the patient & ask them!
Current nursing, other HCPs or social
concerns
Current clinical state
 Obs
 Input/output, stools
 Symptoms & examination findings
Current interventions
 Medications
 Day of antibiotics
Review the drug cardex
 Any ‘devices’ in-situ (e.g. catheters)
 Impression & plan
MEDICATIONS
 Daily review of drug kardex
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Interactions?
Side effects?
Thromboprophylaxis
Allergies
Does the cardex need re-writing?
 Antibiotics
 Indication
 Duration
 Use Trust guidelines
 Warfarin
 Monitor INR
 Ensure prescribed (pre-plan, if possible, for
weekends / bank holidays)
 Manage over / under anticoagulation (see
Trust Guidelines)
 Insulin
 Monitor blood glucose
 Make use of the diabetes specialist nurses
(DSNs)!
WHERE TO FIND TRUST GUIDELINES
PRINT SCREEN
Key guidelines:
• Antibiotics
• Warfarin
• Refeeding
• VRII
• Hyperkalaemia
DOCUMENTATION - BASICS
Top left hand
Title
Bottom right hand
• Date & time (24 hr clock)
• WR + name & grade of most senior
doctor present
• Add speciality if outlier / joint care
• Name + grade/ signature / GMC
number / bleep number
NB. This is a legal document…it should be legible
DOCUMENTATION – CLINICAL INFO
 Age & gender
 Concerns from other members of MDT
 Presenting complaint / reason for
admission
 Clinical review:
 Patient background
 Working diagnosis
…problem list for more complex pts
 Current treatment (inc. day of abx)
 Active problems / issues
 Recent & pending investigation results
 Any nursing concerns
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Patient concerns
EWS score + abnormal results / temp spikes
Input / output
Bowel movements
Examination findings
 Impression
…better than ∆, you can change your mind later!
 Plan + EDD
ABBREVIATIONS & COMMON SYMBOLS
Abbreviations
Common symbols
EWS
ATSP
↑
TWOC
PTWR
∆
↓
↔
EDD
♂
BNO
˜
OE
(previous blood test result)
♀
SNT
Only use if understood by other clinical staff in that setting
FINAL TIPS
Make sure you understand what’s going on with the patient
Update your patient list as you go along
Don't write anything you couldn't defend in court…
…If you didn't document it, it didn't happen
Discuss / clarify plans with seniors as needed
ANY QUESTIONS?