The Things Expected From You That No One Will Teach You!
- Clerking & Documentation
- Requesting & Reviewing Bloods
- Requesting Investigations
- Radiology Requests and Vetting Them
- Specialty Referrals
- Discharge Summaries
1. Clerking & Documentation
This is a very important part of your job as a junior doctor. Whichever specialty you are in, this will be relevant as you will be admitting new patients all the time. The importance of a good clerking is the attention to the right details and those relating to the presenting complaint.
When you are clerking, pay attention to what the patient have come to the hospital with. Many junior doctors get caught up in very unrelated thing such as a non -specific pain they have had for a few years when they have come in with shortness of breath. On the other hand you would not want to miss the colour of someone’s stool when they are having abdominal pain (melena – black stool).
When you are clerking a patient in for a particular specialty, make sure to go into further detail when clerking. Examples include:
Surgical specialties – procedures they have had in the last few years. Medical specialties – history of related disease and details of family with similar conditions Haematology/ oncology – past chemotherapies, scan results, tumour marker levels etc.
This information can generally be found in the patient’s past discharge summaries, hospital systems and by taking a good quality history from the patient or relative.
International medical graduates are never really taught on how to document. Medical documentation also varies between countries and so, we do appreciate it may be helpful to see how doctors in the UK normally document.
Documentation will vary depending on what it is you’re recording. Reviewing an unwell patient may differ to a daily ward round which again may differ to a conversation with a relative however there are some basics which should be present in everything you document. It is after all a legal document. You’ll often hear the expression – ‘if it wasn’t written, it never happened’. It’s important to document relevant information so that there is written evidence of events that have occurred.
LABELLED DIAGRAM with common basics of date, time, name, GMC number etc.
Disclaimer: We appreciate that this may not be the ‘perfect way’ to document, everyone in the NHS have developed their own way and we are sure, you will too, however we’ve tried our best to give you a guide to help you feel more confident and get a general idea!
2. Requesting & Reviewing Bloods
It is your job as a junior doctor to be aware of who needs blood tests and when. You may have a senior to direct you on how often certain patients may need their bloods tested and what they need testing but more often than not, it is your responsibility.
Depending on the trust you are working at, you may have medical assistants/phlebotomists who can kindly help you with taking bloods but even then, they may be short-staffed/busy, so do not wait for them to take the bloods. If you need it urgently then you have to take those bloods, if it isn’t urgent, you can leave it for the afternoon or even the next day.
Be wary of requesting unnecessarily. Do not request bloods every day for patients unless you need them. If you are just routinely monitoring for medically fit patients, they can perhaps have bloods once a week (depending on your consultant). If you need to monitor renal function/CRP then you may need to request bloods every day or every other day. Taking bloods from patients includes inserting a needle and it is an uncomfortable/painful procedure for the patients, therefore be mindful!
In terms on interpreting bloods, you are expected to do that for the basic bloods (FBCs, U&Es, CRP, LFTs) – if you see any derangements and you are not sure what to do, report the bloods/seek help from your senior. If other sets of bloods are needed (Liver screen, Iron studies, Confusion screen), your senior will let you know but it’s always good to learn when these tests are required so you can request them or offer to request them when it’s needed for another patient– your consultant will be impressed!
Always request bloods the day before if you need them the next day – it will reduce your workload!
3. Requesting Investigations
The method of requesting investigations will differ Trust to Trust. Nonetheless any investigation you are requesting, you need to ensure you know why you are requesting them and ideally should be as detailed as possible.
All requests are looked at by the radiographers/radiologists and if it isn’t clinically indicated, your requests may be challenged or a radiologist might suggest an alternative scan if they know exactly what it is you’re trying to find.
If you can, you should also add a query of what you think it is for e.g.? fracture. As mentioned above, if you aren’t sure of the clinical details, ask your senior.
Lady came in with a fall, complains of right hip pain. You will be requesting for XRs of Pelvis/right hip/right femur.
Clinical details: 86 y/o lady admitted with a fall, now complains right hip pain ?? Right Neck of femur fracture (NOF)
If you are requesting scans as an outpatient, there should be an option for outpatients. You then add the time of when you would like the scan to happen. For e.g., Repeat CT chest in 3 months.
4. Radiology Requests and Vetting Them
Now let’s look at what vetting means. Every radiology requests (CT, MRI, OGD etc) that you request for, excluding XRs (occasionally required), you will need to speak to the duty radiologist (registrar/consultant) to VETT the scan.
Vetting essentially means, you have gotten the radiologists to agree with the requests. If the radiologists haven’t agreed with why the scan is indicated, they will not vett it, which means, your scan won’t happen
unless you re-discuss it with them and lay out all the reasons why the patient needs the scan.
How To Vett Scans??
You will need to either ring the duty radiologists on their number or you will have to visit them in their office (depending on the trust).
Whether it is urgent or not, we advise you to call the radiologist to vett the scan as, the quicker it is vetted, the quicker it will get on the day’s scan list. The only difference we would highlight is that, if it is an urgent scan (CT head for a patient who had a fall and is on anti-coagulants or CTPA for ??PE) then you NEED TO CALL and VETT immediately. If it is a non-urgent scan then you can wait and vett it after the ward round when you are going through your job list.
When explaining clinical details, tell them the story of the patient as concisely as you can. Some things are easy to vett whilst others may not be but don’t worry if you aren’t able to vett the scan. Radiologists are specialists in their field and they may not agree with a particular scan for myriad of reasons (not the most suitable for what you are looking for, renal function doesn’t warrant CT etc) so they may give their own advice (to request for another type of scan etc). You can relay their advice to the team.
5. Specialty Referrals
It really isn’t as bad as it sounds or you may have heard. Yes, you are a junior member of the team but it is expected of you to speak to specialty registrars/consultants to either seek their advice or to ask them to kindly review your patient. It always helps to know why you are calling them hence why, if you aren’t sure – ask your senior.
When referring a patient, it’s important to give a good HANDOVER…
What Is A Handover?
A handover involves the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or groups of patients, to another person, such as a clinician or nurse, or professional group on a temporary or permanent basis. Ideally someone can take over responsibility for a patient only if he or she receives all relevant information to continue the treatment or care effectively and safely.
Improving Your Handover
Assessing the key people that need to be involved in the handover (physicians, nurses, and patients and their carers)
Choosing a calm environment with minimal distractions
Providing the person you are handing over to, with the opportunity to ask questions and checking if they have understood correctly (report back).
Giving The Best Possible Handover
Handing over unwell can be patients are tough as there might be a lot going on and this inevitably might make you forgot certain details regarding the patient.
To help you to handover efficiently and effectively to ensure safety of patient, there is an internationally accepted way of doing this.
The SBAR method:
SITUATION—A concise statement of the problem (what is going on now)
“I am calling about Mr Brown; he is on the orthopaedic ward. I saw him five minutes ago and he was dyspnoeic, breathing heavily, and had difficulty finding words.”
BACKGROUND—Pertinent and brief information related to the situation (what has happened)
“He is six days postoperative after total hip surgery, wound is healing. He is not fully mobile yet. Dalteparin 5000 units, no diuretics, 1 L NaCl IV, no allergies, normal infection parameters. Vital functions: blood pressure 110/75 mm Hg, pulse 105 beats/min, temperature 37.8°C, breathing frequency 35breaths/min, oxygen saturation 88%, no additional oxygen. He has a history of cardiac problems, but exact details not known.”
ASSESSMENT—Analysis and considerations of options (what you found or think is going on)
“Patient is deteriorating rapidly, he has severe problems with breathing; his breathing is shallow, and his lips are pursed. I think he might need artificial respiration or additional diagnostics to find out the cause.”
RECOMMENDATION—Request or recommend action (what you want done)
“I am worried and want you to come to the ward immediately for a second assessment of Mr Brown. Is there anything I should do in the meantime?”
6. Discharge Summaries
A discharge summary is given to a patient and their General Practioner/Family Medical Doctor detailing the events of a patient’s stay in hospital and the medications a patient has left the hospital with.
It usually falls upon a junior doctor to complete and more often than not is done so without any explanation of what to do or how to write one.
Discharge summaries can be very exhausting to do, especially when you have to sit there doing one for a patient who has been on the ward for 4 months and nobody had bothered to start it (we’ve all been there!)
A good tip is to start your discharge summaries early. When you have days on the ward where you have completed your jobs and you have time till you finish work, use that time to start those discharge summaries and start with the one who is going home the soonest.
A discharge summary consists of two main parts – a letter that should detail the events of the patient’s stay in hospital and a list of medications the patient will be going home with. These medications must be dispensed from the hospital pharmacy so once you have prescribed the medications on the discharge summary, it’s a good habit to liaise with your pharmacist as they can then help you by screening the medications. Only once the pharmacist screens the medications on the discharge summary, can the medications be ordered from the pharmacy (if needed) and therefore, patient can be discharged.
Pre-emptively doing discharge summaries will potentially prevent stress on a busy day and it will also help your ward pharmacist plan their day as well.