Chapter 3

Lots of junior doctors do not realize the importance of accurate note keeping, and at the time, it may seem irritating. However, if the worst were to happen and an adverse event occurred, accurate medical paperwork can make a huge difference if a lawsuit was brought against the hospital. As doctors communicate with many people through forms and notes, it is important that they contain clear, accurate information. The most important part of paperwork is writing clear, legible patient notes. One of the most important parts of using an EMR is accurately typing information. When you start at your new hospital, ask your predecessors to show you any shortcuts for EMRs or if there are any favourite lists they use for blood requests. Ask them to show you how to do these on your own version of EMR.

The following chapter mainly refers to paper records, but most of it is also applicable to EMRs.

Although most medical records are still written, particularly notes made on ward rounds and reviews, it is becoming increasingly common for hospitals to move towards ‘paperless’ systems. Some trusts now require all emergency admissions and clerking to be recorded on EMR.

As an aside, given the ubiquity of computers, it is worth making sure your typing skills are up to scratch. If you haven’t already developed a fast typing style, it is worth spending a few evenings learning to touch type. This can dramatically improve your productivity and is a skill that will remain useful throughout your career. You can find good teaching programmes in most computer stores or online.

Patient notes

Doctors are expected to write in patients’ notes at least once every 72 hours. However, it is good practice to write something daily and waiting 2 days to fill in notes is unlikely to endear you to the powers that be. More importantly, you may well forget what you have said to your patients on that particular day. It is much more sensible to write in the notes as you go along, or, if there are two of you, for someone to scribe whilst you are with the patient on your ward round:

  1. Always sign notes with your signature and print your surname clearly with your level and bleep number. Some hospitals provide stamps for this purpose. If you make a mistake and cross anything out, also put your initials or sign your name by this as well.
  2. It is useful to ask two things when writing patient notes:

    • Do the notes give enough information to treat the patient when I’m not available?
    • Will I be legally covered if these notes were ever before a court?

  3. For daily notes, there are various standardized ways but the most popular is SOAP (see the succeeding text).
  4. The most crucial aspect of any entry in the patient’s notes is the plan. If you know when a scan or test is going to be done, it is helpful to document this in the notes, so the next person who sees them will have this information available to them. With shift systems in place and plenty of handovers, it is often difficult for someone reading the notes to tell what is already in motion. For decisions that may have to be made in your absence, it is essential to document clearly a decision tree, for example, ‘If systolic BP drops below 100 mmHg, stop GTN infusion’.
  5. If you’re not sure about how to document a patient’s condition, flick back through previous notes and see how others approached it.
  6. It is imperative to include the time and date in the margin of notes. Also, if you are documenting a ward round, you should always note the surname and designation of the person leading the round at the top of your entry.

  1. If you are called to see a patient, briefly document (even if the call was trivial):

    • That you saw the patient
    • The time and date
    • Your plan of action (even if you just want to continue with the current treatment plan)

  2. It is foolhardy to write anything in the notes that you would not want the patient or relatives to read; they have legal access to the notes. When writing in notes, it is best to remain objective at all times, and simply document discussions as they happen without putting an emotional slant on things. This is particularly helpful when documenting discussions with patients about ‘do not attempt resuscitation’ orders or advanced care planning. Often it can be helpful to put what patients or their relatives have said in quotation marks in the notes, if you feel this will benefit the documentation.
  3. It is perfectly admissible to write ‘no change’ if nothing has happened to the patient but be careful that there hasn’t been an important change you have missed. Writing ‘Patient well, continue’ doesn’t look good if they’ve actually been spiking temperatures or have deteriorating renal function! If you are worried that you don’t know what changes to make, it is always better to ask your seniors earlier in the day rather than later. Some consultants or registrars do ‘board rounds’ or ‘paper rounds’ where they discuss patients verbally. Ask them what changes they want to make in each patient’s plan at that time, so you can press on organizing the jobs in a timely manner.
  4. Don’t forget to document the social or psychological aspects (e.g. whether the patient is cheerful, sad or fed up).

Incident forms

When called to see a patient who has had an adverse incident (e.g. fell out of bed):

  1. See the patient as soon as possible. Nurses are legally liable unless they make sure you see the patient. Never be short with a nurse who is making a reasonable request even if you are very busy. It is their job to call you with their concerns.
  2. Ask the patient what happened. Get a history from the nurse or any witnesses. After a quick ‘airway, breathing and circulation (ABC)’ emergency assessment, check the following:

  3. Sign an ‘incident form’ or ‘Datix form’ (the nurses will give you one). Filling it in is self-explanatory. In some hospitals, the nurses will do this online, in which case you don’t need to worry unless there is particular information or concerns you want to pass on.
  4. Also write in the patient’s notes. Include the following:

    • Your name and designation.
    • Time and date.
    • Brief history of accident, witnesses or nurses history of the incident.
    • Examination findings. Often doctors document their assessment as an ABC approach in the notes. Make sure you document your examination findings clearly, so if the patient clinically deteriorates, this can be seen easily.
    • A plan including a note that you must be contacted if the patient’s vital signs deteriorate or there is concern.
    • That the nurses have filled in an incident form.

  5. Ask the nurses to continue doing neurological observations at regular intervals. This includes calculating the patient’s GCS, usual observations, pupil reaction and limb movement. Specify how often you need them done. Try and be reasonable so as not to overburden the nurses with unreasonable requests. However, if you are worried and feel that a certain frequency is required then you must be firm about this. You are responsible for making sure the patient does not come to harm.
  6. Think about how the incident occurred. Consider referral to other teams as necessary, for example, a hospital falls team. Depending on the history, the patient may need an electrocardiogram (ECG), lying and standing BP to exclude postural hypotension, echocardiography or a 24-hour tape to look for arrhythmias (see common calls).
  7. Consider carrying a couple of incident forms in your personal folder or at least knowing where to find them. It can save time in the middle of the night.

Blood forms and requesting blood tests

  • Again, many of these forms are now electronic.
  • Ask the lab which details on blood cards are essential. Often there are spaces on the card for information that isn’t needed.
  • Write your bleep and ward number clearly on blood cards so the labs can contact you if necessary.
  • Good times to fill in forms are during the ward round, when writing in patients’ notes or when you are checking each patient’s blood results. Having forms ready saves time.
  • Where possible, anticipate patients’ blood needs and write forms in bulk. Conditions for which it is sometimes possible to fill in serial forms include those shown in Table 3.1.
  • Try having a separate plastic bag or paper clamp for each day of the week in the doctors’ office. You can write serial forms at the start of the week. Many hospitals now have phlebotomy folders that can be used for this very purpose.
  • If you don’t have a phlebotomist, don’t despair. Taking bloods in the morning enables you to sort out patients’ problems before the ward round. Make sure you take round a trolley like the phlebotomists do. This has remarkable effects on one’s efficacy. Make sure you label each patient’s bottles as you take the bloods. This avoids mix-ups and confusion between different patients. Having your blood forms written in advance also saves vast amounts of time.

Table 3.1 Conditions for which it may be possible to fill out serial forms.

Acute coronary syndromes
On admission
Days 1–3 Lipids (only worth doing within 12 hours of infarct, unreliable post-MI for 3 months)

Serial troponins

Serial ECGs
Warfarin initiation Check the INR at least

Every day for 1 week

Every week for 3 weeks

Every month for 3 months

Every 8 weeks after that
Renal failure
Daily Urea, creatinine and electrolytes
Daily Creatinine and electrolytes
Monday, Wednesday, Friday LFT, calcium, phosphate, alkaline phosphatase
Weekly Magnesium, zinc, FBC, urea
IV fluids Daily urea, creatinine and electrolytes
Post-op bloods
Next day Urea, creatinine, electrolytes and FBC

Discharge summaries (TTO/TTA)

The discharge summary or ‘TTO’/‘TTA’ (to take out or away) is a sheet or electronic form that junior doctors write for patients to take to their general practitioner (GPs). It enables GPs to continue with outpatient care. The TTO is also the prescription form that the nurses use to order drugs for patients to take home with them. The vast majority of units now have electronic TTAs that incorporate the medications with space for a freehand discharge letter, and so you may not have to do both. Paper TTOs are commonly still used on day surgery units or for those having elective day cases, where they are generally used for prescribing medication and summarizing the result of the procedure:

  1. Get the GP’s name and address from the patient, the front page of the notes or the EMR.
  2. Complete the TTO before the patient leaves! Include the following:

    • Patient details (name, DOB, hospital number)
    • Name of consultant
    • Diagnosis
    • Important results (positive and negative) including blood test results, ECG changes or scan results
    • Treatments given during admission
    • If the patient saw any specialist teams during their inpatient stay
    • Whether they were seen by the allied healthcare professionals, for example, dieticians, physiotherapists, occupational therapists, social workers, etc., and if any changes have been made to their social setup in the community
    • Treatment on discharge
    • Follow-up arrangements, for example, outpatient appointments with the consultant (dates and times are useful), or any follow-up procedures or scans
    • What the patient has been told
    • Your name and bleep number

  3. Patients are often delayed in hospital because TTAs have not been written. Write them as soon as possible so that drugs can be fetched from the pharmacy and ideally 24 hours in advance. Patients will love you for this as it avoids them sitting around all day waiting for their medications to arrive from pharmacy. Nurses and the bed manager will love you as you have now freed up a bed for them that they desperately need. Some hospitals in fact now have a pre-11 a.m. discharge policy and require all discharge summaries to be written 24 hours prior to the patient leaving to ensure a smooth discharge process. Remember that this is work you are going to have to do anyway and not only is doing this in advance a marker of being a ‘good’ efficient doctor who is popular with seniors and nurses but it also means that there will be less patients on the ward for you to have to manage as they will be ready for discharge. It will similarly cut down the inevitable bleeps that will start coming from nurses as soon as the decision to discharge is made (when you will still be on the ward round and unable to help). However, DO NOT sign off TTAs until the day the patient is leaving. It goes without saying that prepared TTAs will need a final check for any recent changes.
  4. If you have a paper system, you can carry a bunch of TTOs on ward rounds so that you can write them on the spot when the decision is made to send someone home. If you are on an electronic system and a decision is made to send a patient home on the ward round, do a quick mental check to make sure that there are no outstanding issues you are unsure about like follow-up time or anticoagulant plans.
  5. Phone the GP on discharge if the patient:

    • Self-discharges
    • Is in an unstable condition
    • Has complex home circumstances/care needs

    • Is elderly/terminally ill
    • Dies
    • Needs an early visit or a repeat blood test done locally soon after discharge


Before you go home or away for the weekend you will need to ‘hand over’ your patients to the doctor who replaces you. A formal handover is really helpful for your colleagues taking over. I would recommend that you avoid a handover like ‘There’s a Mrs Smith on Ward 4 to be seen. See you in the morning’ – your colleagues will not thank you and Mrs Smith may never get the review that she needs. At best you will then have to do it yourself tomorrow, at worst the patient may come to harm. Obviously how much detail you tell your successor depends on whether or not they are familiar with the patients – bear in mind that they may not know them at all. In these changing times of the European Working Time Directive, handover is becoming ever more frequent and important. Sometimes handover is done verbally, but some hospitals have an electronic system that requires you to fill out a form that the weekend or night doctors on call use. You need to make sure your successors know the following:

  1. Who your patients are, which ward they are on and why they are in hospital.
  2. A brief summary of the management of each patient (e.g. awaiting surgery tomorrow, NBM, needs continuous morphine infusion for pain relief but stable). Also state specifically what jobs they need to do and why. If asking someone to check some bloods, tell them what to look for and what to do if there is an abnormality, for example, please check Mrs X’s bloods, specifically her creatinine. If it has continued to rise please adjust her IV fluid supplementation.
  3. Likely complications or difficulties and how you have been dealing with these to date, as well as what to do should they arise.
  4. Anyone (doctor/nurse/relatives) who may be contacted if problems arise.
  5. What the patient’s ceilings of care are if they deteriorate, that is, resuscitation status or if they are for intensive therapy unit- or ward-based care.
  6. It is good practice to ask for a ‘hand back’ in the morning or after the weekend to find out what has happened in your absence.

Referral letters

If you need to refer a patient to another team, you can phone the registrar to make a verbal referral and leave relevant details in the patient’s notes. Alternatively, you can write the consultant a letter. You may also be required to write email referrals. If you write a letter, include the following:

  1. Address the letter to the consultant of the other team.
  2. Name of your consultant, yourself and your bleep number.
  3. Name of patient, age, sex, DOB, hospital ID and current location (e.g. ward/home).
  4. Name of patient’s GP.
  5. Specific question(s) your team needs to be answered and the reasons for referral.
  6. Relevant clinical history and examination findings.
  7. Recent investigations (including negatives).
  8. When you need his or her advice by (write this in a humble way!).

Try to anticipate which investigations the other team might need and include them in your referral letter. For example, surgeons almost always need a recent full blood count (FBC), clotting, group and save and maybe an ECG and chest X-ray if they are considering theatre. Gastroenterologists, or any specialist doing a biopsy, will want an international normalized ratio (INR (prothrombin ratio)) and platelet count if investigating liver complaints.


However it may feel, hospitals are not prisons. Unless patients seem likely to incur life-threatening harm to themselves or lack capacity to make decisions regarding discharge, you cannot restrain them from leaving hospital – even when it is patently a bad idea for them to do so. If your patient decides to leave against your advice, try the following:

  • Explain to them why they should stay and the risks they are taking by leaving.
  • Try to find out why they want to leave, and see if there are any issues you can help them resolve.
  • Inform your senior and the sister in charge of the ward.
  • Have the patient sign a self-discharge note. This is usually available from the ward clerk. If necessary, you can write one yourself. You need to have a second witness to sign the note. Ensure the patient’s name, DOB, hospital number and the name of the hospital you work in are on the form, and then file this in the patient’s medical notes.

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