Medical patient review

Summarise the patient’s case 

• Demographics: name, age
• Patient background: comorbidities, medical history
• Admission details: date of admission, presenting complaint
• Diagnosis/diagnoses/differentials so far
• Management so far
  • Investigations: results of important investigations the patient has had during this admission 
  • Treatments
• Planned management
  • Management plan
  • Stage reached
  • Why they are still in hospital

Note: whenever you see a patient you have not previously reviewed yourself, you should go through everything in detail – don’t just accept other people’s diagnoses/plans. If you have reviewed a patient before and been through the case in detail, a basic diagnosis/problem list every few days will usually suffice. 

Investigation results review

• Latest bloods and trends, e.g. haemoglobin, inflammatory markers (WCC/CRP), other relevant blood results
• Other new investigation results

Patient assessment

Questioning

• Current symptoms: determine current symptoms, explore as usual
• Changes since last review/coming into hospital
• Concerns
• Functional assessment: eating/drinking, bowel habit, mobilisation

Nursing charts

• Observations: review current condition and trends on observation chart/temperature spikes
• If being recorded and relevant

  • Stool chart: check when last opened bowels and stool type
  • Capillary glucose chart (if diabetic): check the range of glucose levels
  • Fluid chart: check input, output and balance
  • Food intake chart

Examination

• Focussed system examinations as relevant

Plan and medications review

• Make plan (including further tests/management)
• Review current medications (don’t forget about VTE prophylaxis!)

Tips!

• Reviews must be patient-centred (treat the patient, not the disease). Consider:
  • Disease
  • Comorbidities
  • Social factors: home, family, carers (involve nurses and occupational therapists)
  • Occupation (e.g. type of work if epileptic)
  • Mobilisation status (involve physiotherapists)
  • Polypharmacy (involve pharmacist)
  • Strength/habitus and diet (involve dietitian)
• Consider making a problem list
• Ensure you always think about why a patient is still in hospital and think about their case with a view to discharge 
• It can be difficult to build and maintain good patient relationships when you are busy and have a long list of jobs to do. Some tips
  • Introduce yourself properly
  • Check what they like to be called and use that name throughout the consultation
  • Ensure you check for their concerns/questions at the end