Table of Contents SummaryInvestigationsPatient assessmentPlanExample SIPP may be used to remember the main sections Summary Investigations reviewed Patient assessment (questioning + charts + exam) Plan Summary Summary or problem list or list of diagnoses made so far this admission Important management so far NB: this may not be done everyday. Investigations Investigations results reviewed on ward round Patient assessment Questioning: note anything the patient says Charts: e.g. fluid balance, weights, bowel chart, glucose chart (for diabetics) Examination: current observations, how the patient appears (e.g. well/unwell), system exam findings (use diagrams as well as writing findings) Plan Numerical plan Example Example ward round documentation
