Patients’ Notes

It is the official policy of the Thoracic Surgical Department that a note is written in the chart on every patient,every day. This will be checked by the Consultants on official ward rounds. This is both for clinical and medico-legal purposes.

With more crosscover arrangements for junior staff it is imperative that a clear note is given to those covering at night and at weekends to indicate what the patient’s status is and what is the planned treatment. Ideally such a note should be of the format:

  1. Subjective - what the patient reports e.g. " I feel better today, the pain has gone".

  2. Objective - what the doctors found on examination and tests "Chest clear, WBC normal"

  3. Assessment - diagnosis & current status "Day 3 post lobectomy, no complications"

  4. Plan - what direction you recommend "resume normal diet, off monitor, drain to stay"

This is what the Americans call a "SOAP NOTE" - so they can remember the order to put things! I suggest that on either the morning or evening round one person can examine the patient , one can write the note and one can try to find where the Xrays went!

Notes should be made after any procedure e.g. drain insertion, drain removal and when there gas been a significant change in the patient’s condition.

Patients transferred from ICU/HDU should be re-clerked in with assessment, summary, problem list, plan, drug Kardex, physio, dietetics referrals etc.

Chest X-rays are returned to the ward unreported by the radiology department. There is a legal requirement that all X-rays are reported and that report is recorded in the chart by a suitably qualified doctor. On the Thoracic ward that doctor is the registrar. It is therefore a legal requirement that the registrar reports all the portable and department CXR films and that a note is made in the chart documenting that report.