In this climate of increasing litigation, it is imperative that good medical records are kept. Here are some tips on how to make the most of the crucial consultant ward round. Junior doctors are all too often mistaken for scribes. Usually at least one ward round is conducted everyday to review the progress of each patient outcome. • In 23 encounters (25%) there was im-mediate communication with the nurse regarding patient management. Write everything that’s said by the consultant/patient Different consultants have different preferences about how they like things written (the above is an example) 2. Using a structured checklist, key aspects of surgical care were observed and recorded during ward rounds. Its use as the basis of structured ward round documentation was then measured. Learning Opportunities … Using a Structured Checklist to Improve the Orthopedic Ward Round: A Prospective Cohort Study Orthopedics. These resources are designed to help Trusts adopt best practices to improve patient safety. Using these tools will help hospitals implement standard templates. For example, it suggests consistent ward round items for review, prompting team members to set and update a discharge date, or determine when to move from IV to oral antibiotics. 1. 3. doi: 10.3928/01477447-20170509-01. 2017 Jul 1;40(4):e663-e667. ... of documentation of an orthopaedic post-take ward round. Identify the most important goal in caring for a patient with orthopedic trauma. -Complete 3rd/4th year med student style H&P card with accompaning daily form for those day to day activies on the ward, ICU or CCU (also get Page 2) Medicine Heavy Duty Scutsheet -For those who love grids and small writing. Ward Round Documentation M. Tips! Methods. Owing to the small sample size, the patients were not subdivided into relevant teams or according to which grade of doctor led the ward round. Authors Adrian J Talia, James Drummond, Cameron Muirhead, Phong Tran. Epub 2017 May 15. 4. Identify methods utilized to diagnose orthopedic … Care of elective orthopaedic patients and trauma patients on the orthopaedic unit. Typical Work Pattern: Rolling rota of full week receiving, week off, post take and elective ward cover. Define orthopedic trauma. There is a regular (twice weekly) ward round by care of the elderly consultant. Use our new template to develop a orthopedics-specific health plan that you can adapt to reflect your institution's changing priorities. Conclusions Following introduction of the ward round template, compliance improved significantly in all safety parameters. Post take ward rounds can be high pace and there is a lot of pressure on junior doctors to document discussions and plans made by the clinician leading the ward round. Key aspects of care may be overlooked on a busy surgical ward round. 5. They frequently trail far behind the consultant, not hearing what has been discussed and writing sparse and irrelevant entries in the notes. Identify complications that can arise related to orthopedic trauma. The template provides direction on four steps of the planning process: performance analysis, market assessment, plan design, and plan evaluation. This study assessed the use of a checklist to correct these omissions. • In 12 encounters (13%) a nurse was present on the ward round. orthopaedic surgery and urology. Leave enough space for each section and write things in the relevant section as they are said (often won’t be in order!) The book is divided into eight sections that include ward round, table of instruments and implants, table of orthopedic radiographs, table of orthosis and prosthesis, bone, joint model and specimen, orthopedic surgical approaches, operation theater and sterilization, and glorious history of orthopedics. 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