Ward round documentation

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