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The Art of Documentation in the NHS: A Junior Doctor's Comprehensive Guide



Documentation is an indispensable aspect of healthcare delivery in the NHS (National Health Service), ensuring accurate recording and accessibility of patient information. As a junior doctor, you play a crucial role in various types of documentation, which can be in paper or digital format depending on your trust and location. In this comprehensive blog, we will delve into the key types of documentation that junior doctors are expected to complete in the NHS.


1. Initial Patient Clerking


As a junior doctor, your journey often commences in the Emergency Department (ED) or when a patient is first admitted to the hospital. Your primary responsibility is to clerk the patient which involves:


- Recording the presenting complaint

- Documenting the history of the presenting complaint

- Noting your examination findings

- Requesting or acknowledging completed investigations

- Formulating an impression and outlining the initial plan for patient management


2. Ward Round Documentation:


Another essential aspect of a junior doctor's documentation duty involves ward rounds, where you work alongside a consultant. During these rounds, you must document the patient's status and interactions with the consultant and the final plan for the patient .


3. ATSP (Assessment of the Sick Patient):


In critical situations, you may be summoned to assess a patient urgently. This typically occurs when a nurse or another junior doctor is concerned about the patient's condition. ATSP documentation follows an A to E format, focusing on your assessment impression and the final plan for patient management.


4. Other documentation


Moreover, as part of your documentation responsibilities, it is essential to include any discussions with patients' next of kin or details of collateral history obtained. This comprehensive record should encompass the review of blood test results and any other findings not previously acknowledged.


In cases where DNACPR conversations take place, documenting these discussions is paramount for clear and ethical patient care. Additionally, in the unfortunate event of a patient passing away, the process of confirming their death should also be meticulously recorded. Furthermore, any advice provided over the telephone should be documented to maintain accurate and comprehensive patient records.


4. Sign Off and Identification:


In all your documentation, including the initial patient clustering, ward round notes, and ATSP assessments, it's crucial to include certain identifying information. These details should encompass:


- Your name

- Bleep number

- Your role

- Your signature


Conclusion:


Documentation is a cornerstone of a junior doctor's role in the NHS. Properly recorded patient information ensures continuity of care and facilitates effective communication among healthcare professionals. Understanding and adhering to the various types of documentation, whether it's the initial patient clerking, ward round notes, or ATSP assessments, is paramount for providing high-quality healthcare services.


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