Registrar Documentation

Registrars are responsible for documenting:

  • Admission summary
  • Discharge summary
  • Documentation during specialist round
  • Important management decisions, inotropes, antibiotics etc
  • Procedures, scans and significant events
  • Discussions with other teams
  • Discussions with family
  • Death and Cremation certification
  • Datasheet form (see discharge policy, deaths in intensive care)

 

Clerical duties:

  • All registrars are responsible for signing results of investigations and laboratory results
  • A file tray in the office contains all unsigned investigations and laboratory results
    • Once signed, the ward clerk will file them in the hospital notes
  • Most results will be known to us
  • Any abnormal results should be drawn to the attention of the clinical team.

 

Admission Summary

 
Should include:

  • Date and time
  • Name of admitting officer
  • Reason for admission
  • History (sequence of events from onset of illness to initial IC admission)
  • Past medical history (co-morbidities)
  • Social history (level of function and QOL)
  • Drug history
  • Examination (ABCDOR)
    • O = Other including abdomen and peripheries
    • R = Results of Investigations
  • Problems list (diagnostic and management problems)
  • Assessment / Impression
  • Management plan
  • Document notification of parent team and intensive care specialist
  • Documentation of starting datasheet
    • Place three stickers, one on each page of the database form and one on the Outreach sheet
    • Complete on admission:
      • Page 1 – Left side of page
      • Page 2 – Co morbidities , Apache II and SAPS, GCS – non sedated pre intubation if possible
      • Page 3 – List diagnoses/problems
      • Page 4 – Start where possible
  • Parent teams should be encouraged to write a short note at least.

Intensive Care Clinical summary

 
The Intensive Care Clinical summary is typed on concerto (CIS).  It can be started at any time after admission and must be completed and finalized before transfer to the ward.  It should include:

  • Summary of sequence of main events during the intensive care stay
  • Current problems (diagnostic and management)
  • Current examination
  • Current treatment and plan (including fluid therapy, drug therapy and advice)
  • Documentation of notification of discussion with accepting team (Named Registrar)
  • Documentation of completion of datasheet
  • Flumazenal / Naloxone.  In the event the Flumazenal and/or Naloxone are used in ICU.  Patient should be monitored in ICU for 4 hours prior to transfer to the ward.  In the ward, such patients should receive saturation monitoring for 6-12 hours and be reviewed by the flight Outreach Registrar within 6 hours.
  • Research / Studies / Trials

Data Entry in the clinical Notes

  • Ensure each page is dated and labelled with the patients name and hospital number
  • Date / time / name of intensive care specialist conducting the round
  • Active problem list
  • A:   Mental state, GCS, airway
  • B:  Ventilation, saturation (or PaO2), chest findings, RR
  • C   Pulse / BP / peripheral perfusion / Precordial exam
  • Abdominal examination and description of feeding mode
  • Peripheries
  • Overall assessment / Impression
  • Plan
  • Datasheet update:
    • After 24 hours, complete physiology data eg: 13/10/12 1842hrs – 14/10/12 1842hrs
    • At any time during the intensive care stay when patient is:
      • Intubated
      • Has any line put in
      • Has echo's
      • Has scans

 

Daily Data Round

 
This round is undertaken daily by the Advanced Trainee Registrar 2, and if available, Specialist Medical staff.

Should include:

  • Intensive Care Datasheet
  • FASTHUG Alerts
  • Tracheotomy documentation
  • Cuff Pressure for ventilated patients
  • Nilstat – Start Day 3 ventilated patients
rounded corners top

Related Documents

rounded corners bottom
Page last reviewed: 13 May 2014
Contact Us
Image of a Phone By Phone
Image of an Email sign By Email

For a full list of the convenient ways that you can contact us, refer to the Contact Us page