Ward Management of Surgical Patients: Administrative Issues
Tips and suggestions for surgical management
Transfer from theatre/ ICU/ High Care
Patient clerking
Patient clerking should be problem oriented and but do not omit important details like referring GP / hospital with full address, past history, smoking, social circumstances, quality of life etc. It is essential that every patient is clerked by a member of the surgical team. Write daily follow-up notes on all patients when relevant. Every complication and its management must be documented in detail. File all special investigation reports in the folder. Relevant post op notes should be made. Order relevant investigations only, and ensure that you get the results and act accordingly. Be conscious of cost and wastefulness.
Afternoon rounds
Afternoon rounds are very important, especially on operation days. Obtain the results of all the investigations requested in the morning. Without these results the afternoon rounds are not very useful.
Transfer from theatre/ ICU/ High Care
Such patients HAVE to be formally re-assessed by the doctors in the ward. They are vulnerable, sicker than the standard ward patient, and at risk from adverse events due to poor communication between various staff members. Check the drug charts, and ensure that the nursing staff is alert to the problems of the specific case. Ensure that monitoring is frequent and standardised. Make sure that the nursing staff have a clear and specific instruction of who to call if a problem arises. Write your name and contact number clearly on the observation charts.
The recommended routine observations for patients transferred from ICU and PAHCU are as follows:
- half hourly observations for 2 hours (that is 4 observations) followed by:
- 1 hourly for 2 hours (that is 2 observations) followed by:
- 4 hourly as per ward routine
This is effective as long as the vital signs remain within normal parameters however, should the patient’s condition be unstable, then continue with ½ hourly observations and inform the doctor accordingly.
Discharge planning
Discharge planning of patients is essential. The decision to discharge patients usually takes place on the morning ward round. Ensure that you set aside time to discuss with the patient their diagnosis, operation performed and follow up plan before they leave the hospital. Make sure that you answer any questions accurately. Because of the reduced number of beds, patients should not be lying in the ward after they have been discharged because medicines has not arrived from the pharmacy, transport or other social problems etc.
Please know your patient’s social circumstances, and plan discharge (transport, placement, transfer etc.) well in advance to avoid these hassles. It is possible to get discharge medications a day before discharge to prevent patients waiting the whole day for the medicines to arrive from the pharmacy before they can go home.
Further follow-up
An integral part of patient’s discharge is further follow-up. Confirm during the ward round where is the patient to be followed up, and the ward clerk can help make the appointment for the patient in the respective area. Most patients are seen at least once at SOPD within 2 weeks of discharge. All patients have to be coded with an ICD number. At the time of discharge a clear, concise, comprehensive summary must be produced by the attending doctor. A copy must be sent to the referring clinicians. ICD10 and ICD9 codes must be reflected on the summary. Electronic hospital records must be updated and correctly entered.
eCCR - the Department of Health is rolling out an electronic patient record program. This is expected to be widely available by the end of 2015. It is fundamental that you familiarise yourself with this system, and that data is coded and entered accurately, to reflect the correct diagnosis and intervention
Clinical Notes
Accurate notes should be made in the patient’s folder about his/her progress. Any complications and procedures should be clearly documented. The notes should be brief and to the point. Write daily follow-up notes on all patients, and a clear, unambiguous follow up plan at discharge. Updated, legible, clear clinical notes are an essential requirement of medical practice. All notes and drug chart entries must be signed and dated; the surname and Persal number of the doctor must be recorded.
St. Luke's Hospice
St. Luke's Hospice provides palliative care to many of our patients, particularly those with terminal cancer. It is essential that the hospice forms are filled in accurately with regards to patient diagnosis and management to date. The referral contact information should include the names of the consultants in the firm as well as the ward contact numbers. The forms should then be faxed through to St. Luke's and a phone call made to confirm receipt of the referral.
Referral to Day Hospital
Referral to Day Hospital or other medical services for post operative care, dressing changes or follow up, should be legible, clear and informative. Always imagine what you would like to know about the patient and his condition, if you were to take the responsibility for further care.