Sharing care with colleagues

  • In hospitals, proper handover and up-to-date progress notes should be considered an essential part of patient care (see Box 16).
  • Nursing and other staff involved in patient care should be kept adequately briefed.
  • If it is in the patient’s best interests and you have their implied or express consent, welfare and voluntary agencies and family carers should be given any relevant information.

Recording essential information

Inadequate medical records are the underlying cause of many failures of communication – the records are the essential tool of communication between members of the multidisciplinary team. Subtle but significant changes may be missed when several different doctors see a patient over many days, unless adequate information is available from previous examinations.

What you include or leave out of the record is a matter of professional judgment, but you should take care to include all information that other members of the team will need to continue care of the patient safely. As months or years may elapse between treatments or illnesses and staff may have changed in the meantime, the records should also serve to reconstruct events at a later date without recourse to memory.

Advice on what to include in the medical record can be found in Box 10 on the Problems in clinical management page. For hints on keeping good records, and advice on access to and disclosure of medical records, ask for a copy of Medical Records – An MPS Guide [view the booklet here].

Box 16: What should be handed over? 

Written (or IT-based) handover should include:

  • Current inpatients.
  • Accepted and referred patients due to be assessed.
  • Accurate location of all patients.
  • Operational matters, directly relevant to clinical care such as ICU bed availability.
  • Information to convey to the following shift.
  • Patients brought to the attention of the critical care outreach team (where appropriate).
  • Patients whose “early warning scores” are deteriorating (where in use).

The following, as well as being included in the written handover, should be discussed within the handover meeting. This verbal handover is vital to highlight these issues:

  • Patients with anticipated problems, to clarify management plans and ensure appropriate review.
  • Outstanding tasks, associated with their required time for completion.

(BMA Junior Doctors Committee, Safe Handover: Safe Patients: Guidance on Clinical Handover for Clinicians and Managers (2004)

   

Keep contcat details up-to-date

It goes without saying that you should inform the hospital whenever your contact details change

If you carry a bleep, you have a responsibility to make sure that everyone who needs it knows its number. When you come on duty, you should write it on the handover sheet during handover, and if you’re on call, you should ensure that the ward staff know how to contact you.

You also have a responsibility to keep switchboard informed of your contact details. It is especially important to keep switchboard informed about your whereabouts if you’ll be travelling between sites – to an outlying clinic, for example.

It goes without saying that you should inform the hospital whenever your contact details – mobile or landline number, address and email address – change. It’s surprising how often people forget to do this, but such a seemingly small oversight can lead to big consequences if you can’t be contacted in an emergency.

You might, for example, have forgotten to pass on some important information about a patient before you went home, and if you can’t be contacted no-one can ask you about it, which may prove crucial in an emergency.

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