The post take ward round - how to prepare for it

This post is about post take ward rounds. As I am a medical registrar, I am going to stick to medicine using examples however this can be used in any specialty. 

In medicine ( and most specialties), patients are admitted via

1. Emergency to the acute medical unit/ elderly assessment unit

2. Directly to the acute medical unit from GP surgeries 

3. Directly to specialty wards from clinics

These patients are then 'clerked' by doctors, ACPs/ANPs, physician associates who:
1. Take a history 

2. Examine the patient 

3. Request relevant investigations 

4. Make a management plan 

I have mentioned more on this here:
How to clerk patients safely and efficiently: 

https://omarsguidelines.blogspot.com/2019/08/how-to-clerk-medial-patients-safely-and.html

Once the patient has been clerked, they are for post take. The post take consultant usually has a doctor(s) with them who scribes/requests relevant investigations. 

The consultant goes through the patients clerking, relevant investigations, medications, previous letters, ambulance sheet and expects the doctor with them to write down the relevant results, with observations. They then go to see the patient. Usually the doctor goes with them and documents whatever they are saying. 

The consultant then asks them to document the diagnosis and management plan. 

ISSUES:

Every consultant has their own 'style'. 

Some consultants :
1. DO THE POST TAKE ALONE 

They document everything themselves ( and some of them have horrible handwriting so it is very difficult to understand what they have written. 

PROS:
If the clerking team is busy, the doctors can continue clerking instead of leaving that shift and doing the post take with the consultant. 

CONS:
-No learning. Some consultants like to teach on the post take ward round.

-If there is no junior with them, only them and God know what the plan is if their handwriting is horrible. And this becomes a major issue when the consultant has left. 

- They may not hand over any jobs from their ward round to the junior doctors unless they read the post take plan ( which wastes a lot of time).

2. DO THE POST TAKE IN A TEAM 

One doctor is the scribe, one doctor is using the computer and they request the team to write down the post take plan 

PROS:
1. Good learning this way 

2. Well organized. You have 2 doctors - hence you, as the scribe do not need to worry about managing the computer at the same time. 

CONS:
The clerking team might struggle with staffing and hence using 2 doctors for a post take might be too much 

3. DO THE POST TAKE WITH ONE DOCTOR 

The doctor is the scribe and the consultant uses the computer to check letters, investigations, OBS, etc. 

PROS:

1. Good learning 

CONS:
It can get overwhelming for the doctor especially if there are a lot of jobs from the post take - like urgent CTPA, STAT LMWH, Call family, discuss escalation plans. 

HOW TO DOCUMENT A POST TAKE WARD ROUND 
The consultant and the junior doctor go through the clerking and document the key findings. 
The best method is the SBAR method which I personally prefer:
S ( Situation- age, sex, reason for admission):
65F, admitted with shortness of breath 
B ( back ground - past medical history):
COPD, IHD, HTN 
A ( assessment):
Events since admission 
Wheezy upon admission
ABG: pH: 7.40 , PCO2: 6.0, PO2: 10 
Treated with nebs, steroids, oral doxycycline 
Bloods: CRP: 10 , WCC: 9.2
CXR: Hyper-inflated lungs 
ECG: NSR
EWS: 1, BP: 120/80, HR: 72/MIN, afebrile, SO2: 90% on air 
Then the consultant goes to see the patient, 

I usually document whatever the patient says when the consultant takes a brief history( the post take section is very small hence I usually continue the documentation of the history on a separate continuation sheet if it goes beyond the post take section). The reason I document it is that sometimes, the history the patient gives to a consultant might be different to what has been giving to the doctor who clerked the patient and this way, nothing is missed in the documentation. 
They examine the patient and usually verbalize :
Chest: bilateral mild wheeze, able to speak full sentences 
Heart sounds normal 
Abdomen: soft non tender, BS+ 
Legs and calves: SNT, no edema

R (Plan):
Continue nebs as still has wheeze 
Continue oral steroids 
Doxycycline for 5 days 
PRN nebs from tomorrow 
Respiratory nurse review 
Estimated date of discharge ( EDD) - 48 hours
Nicotine patch 

A full example:
17th January, 2022 1000 AM 
Post take ward round Dr **** (consultant) 

S: 65F, admitted with shortness of breath 
B: COPD, IHD, HTN 
A: Events since admission 
Wheezy upon admission
ABG: pH: 7.40 , PCO2: 6.0, PO2: 10 
Treated with nebs, steroids, oral doxycycline 
Bloods: CRP: 10 , WCC: 9.2
CXR: Hyper-inflated lungs 
COVID negative on PCR 
ECG: NSR
EWS: 1, BP: 120/80, HR: 72/MIN, afebrile, SO2: 90% on air 
Hx from patient:
Feeling short of breath since 5 days, worse overnight, denies chest pain 
Was wheezy last night, took PRN salbutamol- did not help 
Has mild cough since 5 days, no fever. Still smokes. Agreed to take nicotine replacement

Chest: bilateral mild wheeze, able to speak full sentences 
Heart sounds normal 
Abdomen: soft non tender, BS+ 
Legs and calves: SNT, no edema
DIAGNOSIS: COPD exacerbation - likely infective 

R (Plan):
Continue nebs as still has wheeze 
Continue oral steroids 
Doxycycline for 5 days 
PRN nebs from tomorrow 
Respiratory nurse review 
Estimated date of discharge ( EDD) - 48 hours
Nicotine patch 
Escalation - full escalation

Signed and dated by consultant

Your job is to document this. It can be shorter than this, or longer depending on the complexity of the patients. Also make a list of jobs like 
Prescribe nicotine patch [ ]

Remind nurses to refer to resp nurses [ ]
on a piece of paper, attach a patients label so that you do not forget ( sometimes patients are transferred to another bed/ward so you cannot just rely on bed numbers)

LEARNING FROM THIS:
We may think that post take ward rounds are like scribing and you do not learn a lot but you do. Here is what I learnt from doing post takes with consultants:
1. Going through clerking and learning from my colleagues on what questions to ask and how to document everything. 
2. Interpreting investigations like ECGs, CXRs myself and then waiting for the consultant to comment on them 
3. Learning how to document. We will all soon be consultants in a few years and we should know how to document post takes ( documentation is taken very seriously here. This is the only evidence in court if a mistake happens) 
4. Observing the consultant take a history from the patient and asking questions which may have been missed 
5. Observing the consultant examine the patient - for example, doing a quick neurology examination in a patient with ? stroke ( consultants are very thorough yet quick and you can learn how to examine patients more efficiently). 

6. How consultants interact with patients and make a management plan. 

7. How they calculate the estimated date of discharge 

8. Most consultants also do teaching at the same time. 

FAQS:
I have been asked to prepare a patient for the post take. What does this mean? 
This means that you go through the clerking history documented already and go through the investigations, old clinic letters. 

Then ask the consultant what they would prefer - ie, would they prefer you to document or would they like to document themselves? Most are okay with juniors documenting. 
Lets take the COPD case above. You can present this case as:
' This 65 year old female was admitted with shortness of breath. Her Background includes COPD, IHD and HTN. She is still an active smoker and lives independently. Upon arrival, she was wheezy and hence was given nebs, steroids, oral doxycycyline. her ABG showed hypercapnia and normal pH ( at the same time show the results to the consultant), Bloods show slightly elevated WCC, CRP of 10, CXR shows hyperinflated lungs. Her medications include: prophylactic dalteparin, oral doxycycline for 5 days, oral prednisolone, regular and PRN nebs. ( show drug chart at the same time) ' 
Document as above ( the SBAR format) and the consultant might ask more questions like :
Lets see if she was admitted recently ? 
I have noticed that her Hb is 99, what is the trend like? 
What were her observations with the ambulance team when they went to assess her? 

Document these as well. 

Then document the history the consultant might take and examination findings. 

Then document the plan 
Make a list of any pending jobs. 

Can I ask questions? 

Yes - certainly! 

My consultant seems to be in a hurry and is not teaching me a lot. 
There can be up to 20 patients to see. Hence you may notice that sometimes, there is less teaching. I have noticed that most consultants are willing to teach but it may be brief. You can still learn like opening a CXR of the same patient and commenting on what you think and seeing if the consultant agrees. 

This is too overwhelming! How can I do everything on my own! 

It can be , initially especially if you have a consultant who works very fast. 

Most consultants will sit at the computer, open the results and verbalize. 

This is what helps:
1. Go through the clerking 2 minutes before the consultant comes 
2. Open the patients details and investigations on the computer- results, CXR 
3. Quickly document a summary which in the above case is:
17th January, 2022 1000 AM 
Post take ward round Dr **** (consultant) 

S: 65F, admitted with shortness of breath 
B: COPD, IHD, HTN 
A: Events since admission 
Wheezy upon admission
ABG: pH: 7.40 , PCO2: 6.0, PO2: 10 
Treated with nebs, steroids, oral doxycycline 
Bloods: CRP: 10 , WCC: 9.2
CXR: Hyper-inflated lungs 
COVID negative on PCR 
ECG: NSR
EWS: 1, BP: 120/80, HR: 72/MIN, afebrile, SO2: 90% on air 

4. You can then verbalize a quick summary to the consultant or let them read through the clerking. 
5. Then take a clipboard so that you can document easily ( I usually use the patients bedside table as a surface to document everything) 

6. Make a list of jobs to do after this 

7. ALWAYS ask the consultant to sign at the end - the reason being is that this confirms that they have read and agreed with whatever you have documented. 

It gets better with time and you soon become efficient. All of this efficiency helps in the long run- as a doctor on call, registrar and then consultant. 

There has been a serious incident regarding a patient I documented the post take ward round for. Am I in trouble? 

No, the consultant who saw the patient is ultimately responsible. You are just the scribe. Hence my suggestion of always asking the consultant to sign at the end of the post take as this confirms that they have agreed with your documentation. 

SOME TIPS:
1. It will feel overwhelming initially - but with time, you will become more efficient 

2. Some consultants like documenting everything themselves so always ask before you start. A simple question like 'Are you okay if I document?' can clarify this 

3. If the consultant is going too fast, request them to slow down a bit. If you do not understand what they are saying, request them to repeat it. 

4. Document whatever the conversation is between the patient and consultant. I learnt this when I was a SHO and a patient came in with a headache. The consultant took a detailed history and I continued scribing and there was around 2 pages of documentation. The patient was discharged but this was followed by a complaint. The consultant went through my documentation and was easily able to gather all the information ( like absence of red flags, etc) and he was easily able to clarify everything. 

5. Keep a job list - otherwise you can easily forget what was in the post take ward round 

6. Learn! Use every opportunity to learn and gain knowledge. 

7. Ask questions, make suggestions. Consultants like it when there is a bit of interest from junior doctors. They will definitely appreciate it. 

8. If something is missing ask, like 'is this patient for full escalation? ' and then document it.