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SELF REVIEW SECTION
The aim of this self-review section is for you to compare your record keeping skills with a senior trainee’s documentation example. Watch the two video’s and write an entry as if you were writing in the patients notes.
We have provided an example of what the entry for this exercise should include. Compare the entries and use the reflective log (which can be printed) to consider your strengths, learning and development needs.
For further support contact the Professional Support Unit (PSU).
TASK ONE
Please click below to watch a clip from the ward round video that you have seen earlier. Your task is to imagine that you are the junior doctor in the ward round. Make an entry in the patient’s notes of the ward round so far.
View the 'TASK ONE - EXAMPLE ANSWER' tab at the bottom of the page after attempting the task.
TASK TWO
In the second video you are the doctor in the outpatient clinic taking the history from Mr Smith. Please watch the clip and document the information obtained.
View the 'TASK TWO - EXAMPLE ANSWER' tab at the bottom of the page after attempting the task.
Date and Time
Ward Round
In attendance: Dr Saman Ahmed (Consultant), Michelle (Nurse), Tanya (Patient), Ali Ajaz/Name of person completing the task (CT1 doctor).
Tanya was in attendance from the start of her ward round which began with feedback from the nursing team.
Nursing Feedback:
Tanya has been overall been making good progress as she has been getting up for her medication on time, attending group sessions and had started psychology sessions too. There has been a noticeable improvement in her mental state, especially since her antipsychotic medication was changed.
Dr Ahmed suggested that leave may be appropriate to consider due to Tanya’s progress. The nursing team mentioned that Tanya admitted to hearing voices the day before when in her room. Tanya agreed that this was the case but that “they haven’t been as bad this morning.” It was agreed for Tanya to start escorted leave with one member of staff.
Tanya appeared pleased with her leave. She also reported that she had been experiencing side-effects from her current medication.
Signed:
Title/Role:
Date and Time
Outpatient Clinic (Dr Vickers)
Mr John Smith, 43 year old secondary school teacher
Presenting complaint – Altered bowel habit for the last two months -fluctuating from loose motions to constipation
History of presenting complaint – He opens his bowels up to 4 times a day when they are loose and can then go up to 3-4 days without passing any further motions. Prior to 2 months ago, he bowel habit was regular at once a day. There is no fresh blood in the stools but has noticed that the colour is darker than usual, which may be blood, no mucous. No abdominal pain or pain around the anus. Family have noticed that he has lost weight although he has not weighed himself. Also reports feeling more fatigued over the last 2-3 months. No dyspepsia, appetite is generally normal. No previous problems like this and no abdominal surgery in the past.
Past Medical History
Previously fit and well.
No angina, no asthma, no diabetes, no jaundice.
Family History
No illnesses reported. Parents and two siblings are alive and well. No history of bowel problems.
Drug History
No allergies.
Not taking any regular medication currently.
Social History
Currently married with no children
Non-smoker
Alcohol – occasional glass of beer at the weekend
Systems Enquiry
No: chest pain, shortness of breath, dysuria or increased urinary frequency, dizziness, fainting
Signed:
Title/Role: