A ward round produces a progress note for each patient, and on discharge days a discharge summary. A note drafted at the bed is built from what was said there. A note written in a batch after the round is written from memory.
What each stop leaves in the record
A progress note carries the observations, the examination findings, the decision and the reason for it, the tasks with a name against each, and the escalation numbers in the words the consultant used. A plan written only as "discussed" gives the covering doctor nothing to act on overnight.
The discharge summary
The discharge summary carries the admission diagnosis, what was done, the discharge medications with every change marked against the admission list, the results still outstanding, and who follows each up. A pending specimen is named in it with the clinician who will act on the result.
It is assembled from the progress notes, so a thin entry from day two surfaces here as a gap somebody fills from memory. The GP who receives it acts on the medication list and the follow-up instructions with no access to the ward's conversations.
Goals of care conversations
The record of a goals of care discussion, the element most often reduced to a single line, needs who was present, what was explained, what the family said back, the decision reached, and whether an advance care directive sits in the chart.
Consent at the bed, and the bay next door
Consent is asked at the bed before capture starts, in a sentence the patient can answer, and the answer goes in the note. A patient who declines has that encounter written by hand and the refusal recorded.
A microphone at one bed can pick up the assessment through the curtain at the next, so ask any vendor how audio outside the encounter is handled, whether raw audio is kept, and for how long. Those answers belong in the health service's privacy assessment before any capture on a ward. Capture quality follows microphone distance: a phone near the conversation and a device at the bay workstation record different audio.
From draft to signed note
The clinician reads each draft against what happened at the bed, corrects it and signs it, and the note is attributed to whoever signed.
The hospital's medical record stays the source of truth, so a signed note has to reach it through a workflow the ward can run once for every patient on the round.
- where a signed note lands in the record system, and how many steps that takes per patient
- who reviews and signs when an intern drafted the note and the consultant is in clinic
- who owns the privacy assessment, and what the vendor answers in writing before capture starts
aurii on a ward round
aurii captures each bedside encounter as its own session on the clinician's iPhone or iPad, so a draft stays attached to one patient as the team moves down the list. It drafts the ward round note from what was said at the bed.
A cardiology round is worked through problem by problem at documenting a cardiology round.
The clinician who reviews and signs the note is its author, and hospital policy on senior review and countersignature applies to it as it did before.
Signed letters go to the GP over Medical Objects. Before a ward trial, confirm where a signed note lands in your record system and how many steps that takes per patient.
This is general information about documentation on ward rounds. It is not clinical or legal advice.
