Steps to write the ward round

The Basics

Patient medical records must contain the identity and complete information of the patient and
doctor. So we must fill it carefully so it would not cause a problems later

1. Patient details

For every new sheet of paper your first task should always be documenting at least three
key identifiers for a patient:

 Full name
 Date of birth
 Unique patient identifier
 Patient’s home address

2. Location details

You should indicate the patient’s location on the continuation sheet:

 Hospital
 Ward

How to make an entry in a patient’s notes

1. Add the date and time (in 24hr format) of your entry 

2. Write your name and role as an underlined heading

3. Make your entry in the notes below this heading

4. At the end of your entry to need to include the following:

 Your full name

 Your grade/role (e.g. Medical student/F2/Neurology registrar)
 Your signature
 Your professional registration number (e.g. GMC number)
 Your contact number (e.g. phone/bleep)
How to clean your body after going outside to avoid Covid-19

To avoid from Covid-19 please take everyday preventive actions:

 Firstly, you need to wash your hands with soap and water for at least 20 seconds with 6
steps washing hand according to WHO, especially after blowing your nose, coughing, or
sneezing, or having been in a public place. (If soap and water are not available, use a hand
sanitizer that contains at least 70% alcohol.)
 Secondly, you should take a bath immediately after arrived at home and make sure you
have washed clean with soap and water (don’t forget to wash your face and brush your teeth
too)
 Thirdly, you must change clothes that have been used to leave the house and wash the
clothes immediately
 Fourthly, you need to clean your smartphone and other items that you want to use after
you’re use it in the outside with wet tissues or other antiseptic material before you use it
again
 Finally, you can take a rest after a long day.
HOSPITAL: Gray Hospital PATIENT NAME: Gita Devi Savitri
WARD: 25
DATE OF BIRTH: 27/7/1992
CONSULTANT: Dr Paulus Partohap HOSPITAL NUMBER: Z978473

DATE/TIM DOCUMENTATION
E
4/5/2020 Dr Wilbert Ross – Obstetrics and gynecology department
9:21 Asked to review patient by Dr Paulus Partohap to discuss patient’s recent
condition of pregnancy.
SJOJ:
- feeling tired and easily fainted
- constipation
- wrist pain
- difficulty sleep
Weight decrease at 52 from 55 kg for last 3 days
Obs (T) 35,9°C, BP 100/70 mmHg, RR 17/min, HR 97 bpm
Plan
1. Continue giving extra intake vitamin (B12, D, C, folic acid)
2. Advice the patient to take a bed rest and give the infusion continuously
The patient is stay in the ward and I will be back tomorrow. If you have any
queries later, contact me on 98576
Dr Wilbert Ross
Obstetrics and gynecology department

Bleep 98576
GMC number 28975