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Ward round documentation

Documentation > Clerking and reviewing patients

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

Clerking and reviewing patients

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