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