Playing the role of scribe on ward rounds is a quick and simple way for any student to make a useful contribution to the team they are attached to.
Alleviating the intern of this duty allows them to focus on compiling their job list for the day, and relieves the medical student of that feeling of ‘being in the way’.
Taking the notes, especially for the first time, can be a bit daunting.
This is a guide that an extremely helpful resident gave me during my first ever rotation.
Hopefully it gives an insight into what is expected, and makes you more prepared than I was when I first set foot on a ward. That being said, if you haven’t taken notes before, your best bet is to ask the intern/resident for their advice, which they should be more than happy to provide.
The essential stuff – important medico-legally and should be replicated each time you write in the notes
- Write in black pen – apparently other colours do not photocopy well, and render the note invalid.
- Time and date – in the left hand column. Time should be in 24-hour format
- Patient ID – stickers should be available in the front of the patient’s file, and are put in the top right corner of the sheet.
- Team details – forms the heading for your entry. Write S/B (seen by) followed by the surnames and positions of those in attendance (including your own). This can be condensed to ‘S/B (consultant surname) + team’ to save time. You can also start with the role of the team (e.g. Paeds WR – Smith + team).
- Days post-op (for surgical ward rounds) – e.g. Day 1 post-cholecystectomy
- Signatures – sign off at the end with your surname and position, but this means nothing without the co-signature of a doctor – make sure you chase the JMO down for these.
Format – a commonly used format is SOAP – subjective (history), objective (examination), assessment and plan. The clinical encounter is likely to jump between these four domains, but try to keep the entry in this order and leave space for further information.
- Subjective – write down what you think is relevant, but have a low threshold. It’s better to write superfluous details than potentially miss things that should be written. The person leading the round is likely to ask the questions so it’s just a matter of jotting down the answers in most cases. The things likely to be relevant in this section are the factors that influence discharge – pain, feeding, drinking, bowel, bladder and ambulation
- Objective – start with general appearance of patient (well, sick, uncomfortable, unconscious etc.). This is followed by the most recent vital signs, available in the nursing chart. Write the details of any examination performed, grouped by system. If unsure of the findings ask the examining doctor – e.g. what were the heart/lung sounds.
- Assessment – listen out for the overall impression that the team has of the patient, and put it into one sentence (e.g. safe for discharge, problems mobilising, requires physiotherapy)
- Plan – number each component of the plan formulated with the patient. This may include, for example, changes to medication, investigations to be carried out/chased up, removal of drains, referral to other services, discharge or simply to continue with previous plan.
Often you’ll find yourself alternating note-taking with the intern, which is great to slow down the pace and give yourself a chance to listen, without having to think about what you are going to jot down next.