Template Structure
Header Information
Date: [MM/DD/YYYY]
Time: [HH:MM AM/PM]
Ward/Unit Name: [e.g., General Medicine Ward]
Supervision Team: [e.g., Dr. Smith (Consultant), Nurse Jones, Pharmacist Lee]
Patient List
[Patient Name or Pseudonym] | Bed/Room Number | Hospital Number
- [e.g., Patient A | Bed 5 | H123456]
- [Add additional patients as needed]
Patient-Specific Documentation
[Repeat for each patient ]
Patient Identification
-
Name: [Full Name or Pseudonym]
-
Age: [Years]
-
Gender: [Male/Female/Other]
-
Hospital Number: [Unique Identifier]
Name: [Full Name or Pseudonym]
Age: [Years]
Gender: [Male/Female/Other]
Hospital Number: [Unique Identifier]
Admission Details
-
Date of Admission: [MM/DD/YYYY]
-
Reason for Admission: [e.g., Chest pain with suspected myocardial infarction]
Date of Admission: [MM/DD/YYYY]
Reason for Admission: [e.g., Chest pain with suspected myocardial infarction]
Current Status
Vital Signs:
- Temperature: [e.g., 37.5°C]
- Blood Pressure: [e.g., 120/80 mmHg]
- Heart Rate: [e.g., 72 bpm]
- Respiratory Rate: [e.g., 16 breaths/min]
- Oxygen Saturation: [e.g., 95% on room air]
National Early Warning Score (NEWS): [e.g., Score 3]
Subjective Assessment: [e.g., Patient reports shortness of breath]
Medical History
- Summary: [e.g., Known hypertension, type 2 diabetes, COPD]
Current Issues
- Active Diagnoses: [e.g., Acute exacerbation of COPD, community-acquired pneumonia]
- Symptoms/Concerns: [e.g., Cough with green sputum, fatigue]
Investigations
- Recent Labs: [e.g., Hb: 12.5 g/dL, WBC: 10.2 x10^9/L, CRP: 50 mg/L]
- Imaging: [e.g., CXR: Right lower lobe consolidation]
- Other Tests: [e.g., ECG: Sinus rhythm, no acute changes]
Medications
- Current Medications: [e.g., Amoxicillin 500mg TDS, Salbutamol 100mcg PRN]
- Changes Made: [e.g., Started on IV antibiotics today]
Allergies
- Known Allergies: [e.g., Penicillin – rash]
Risk Assessments
- VTE Risk Assessment: [e.g., High risk, prophylaxis with enoxaparin 40mg daily]
- Falls Risk Assessment: [e.g., Medium risk, bed rails in place]
- Nutritional Assessment: [e.g., At risk of malnutrition – dietitian referral made]
Antibiotic Stewardship
- Antibiotic Review: [e.g., Amoxicillin appropriate for CAP, to be reviewed in 48 hours]
Palliative Care and Treatment Escalation
- Palliative Care Needs: [e.g., Discussed with family, comfort care prioritized]
- Treatment Escalation Plan (TEP): [e.g., CPR not attempted, oxygen only]
Multidisciplinary Input
- Physiotherapy: [e.g., Mobilization plan: out of bed twice daily]
- Dietetics: [e.g., High-protein diet recommended]
- Other: [e.g., Social worker involved for discharge planning]
Treatment Plan
- Further Investigations: [e.g., Repeat CXR in 48 hours]
- Medication Changes: [e.g., Stop IV fluids, start oral intake]
- Consultations: [e.g., Refer to respiratory specialist]
- Procedures: [e.g., Plan for bronchoscopy tomorrow]
- Discharge Planning: [e.g., Likely discharge in 3 days, home oxygen arranged]
Communication
- Patient/Family Discussion: [e.g., Discussed prognosis and treatment plan with family]
- Consents Obtained: [e.g., Consent for bronchoscopy signed]
Follow-up
- Responsible Team Member: [e.g., Dr. Smith to review antibiotics]
- Next Review: [e.g., Tomorrow’s ward round]
General Ward Issues
- Staffing: [e.g., Short-staffed today, additional nurse requested]
- Equipment: [e.g., Oxygen supply checked, no issues]
- Infection Control: [e.g., Isolation precautions for MRSA patient in bed 5]
Signatures
Supervisor Signature: ___________________________ Date: [MM/DD/YYYY]
Supervisee Signature(s): ___________________________ Date: [MM/DD/YYYY]
Example Note
Header Information
Date: 06/10/2025
Time: 08:30 AM
Ward/Unit Name: General Medicine Ward
Supervision Team: Dr. Emily Carter (Consultant), Nurse Sarah Patel, Pharmacist John Lee
Patient List
Jane Doe | Bed 12 | H987654
Patient-Specific Documentation
Patient Identification
Name: Jane Doe
Age: 68
Gender: FemaleHospital Number: H987654
Admission Details
Date of Admission: 06/07/2025
Reason for Admission: Acute shortness of breath with suspected pneumonia
Current Status
Vital Signs:
- Temperature: 37.8°C
- Blood Pressure: 130/85 mmHg
- Heart Rate: 88 bpm
- Respiratory Rate: 20 breaths/min
- Oxygen Saturation: 93% on 2L oxygen via nasal cannula
National Early Warning Score (NEWS): Score 4
Subjective Assessment: Patient reports persistent cough and mild chest discomfort
Medical History
Summary: Hypertension, type 2 diabetes mellitus, previous smoking history (20 pack-years, quit 10 years ago)
Current Issues
Active Diagnoses: Community-acquired pneumonia, type 2 diabetes mellitus
Symptoms/Concerns: Productive cough with green sputum, fatigue, no fever today
Investigations
Recent Labs: Hb: 11.8 g/dL, WBC: 12.5 x10^9/L, CRP: 65 mg/L
Imaging: CXR: Right lower lobe consolidation
Other Tests: Sputum culture pending, ECG: Sinus rhythm, no acute changes
Medications
Current Medications: Amoxicillin 500mg TDS, Clarithromycin 500mg BD, Metformin 500mg BD, Amlodipine 5mg OD
Changes Made: Started IV fluids (0.9% saline) yesterday due to poor oral intake
Allergies
Known Allergies: None reported
Risk Assessments
VTE Risk Assessment: Moderate risk, prophylaxis with enoxaparin 40mg daily started
Falls Risk Assessment: Low risk, no additional measures required
Nutritional Assessment: At risk of malnutrition, dietitian referral made
Antibiotic Stewardship
Antibiotic Review: Amoxicillin and clarithromycin appropriate for CAP, to be reviewed in 48 hours with sputum culture results
Palliative Care and Treatment Escalation
Palliative Care Needs: Not applicable at this time
Treatment Escalation Plan (TEP): Full escalation, suitable for ICU if condition deteriorates
Multidisciplinary Input
Physiotherapy: Chest physiotherapy initiated, twice daily
Dietetics: High-calorie, high-protein diet recommended
Other: Social worker to assess home support needs for discharge
Treatment Plan
Further Investigations: Repeat CXR in 48 hours, monitor sputum culture results
Medication Changes: Continue current antibiotics, stop IV fluids if oral intake improves
Consultations: Respiratory specialist review requested
Procedures: None planned
Discharge Planning: Anticipated discharge in 4-5 days if stable, arrange home oxygen if needed
Communication
Patient/Family Discussion: Discussed treatment plan and prognosis with patient and daughter, both agreeable
Consents Obtained: Verbal consent for continued treatment obtained
Follow-up
Responsible Team Member: Dr. Carter to review antibiotic results
Next Review: Tomorrow’s ward round, 06/11/2025
General Ward Issues
Staffing: Adequate staffing today, no concerns
Equipment: Oxygen concentrators checked, functioning well
Infection Control: Standard precautions in place, no isolation required
Signatures
Supervisor Signature: Dr. Emily Carter ___________________________ Date: 06/10/2025
Supervisee Signature(s): Nurse Sarah Patel ___________________________ Date: 06/10/2025
Usage Notes:
Customization: This note is tailored for a general medicine ward but can be adapted for other settings.
Frequency: Completed daily during ward rounds for consistent documentation.
Compliance: Aligned with NICE Guideline NG94 and CQUIN targets for patient safety.
Storage: Stored securely in electronic health record system to ensure HIPAA compliance.
Training: Team trained on template use to ensure accuracy and completeness.
This example note aligns with evidence from BMJ Open Quality (2018) on ward round templates and NICE Guideline NG94 (2014) on structured ward rounds, ensuring comprehensive patient care and safety.