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Ward Round Notes

Concise daily ward round documentation template.

Purpose

Ward round notes provide a daily snapshot of patient progress, current clinical status, active issues and the ongoing management plan. They must be concise, focused and timely.

Key Components

  • Date, time and ward round type
  • Clinician name and grade
  • Subjective: how the patient feels
  • Objective: observations and examination
  • Active problems list
  • Investigations reviewed and pending
  • Assessment and progress
  • Plan for each active problem
  • VTE assessment status
  • Discharge planning update

Documentation Tips

  • Use problem-oriented format for complex patients
  • Record specific NEWS values, not just "stable"
  • Document who was present during the ward round
  • Note if patient/family informed of plan
  • Clearly document any changes to medication
Reminder: Always date, time and sign all clinical entries. Include your name and GMC/NMC number.
Template
DATE: ___________  TIME: ___________
WARD ROUND TYPE: Consultant / Registrar / SHO
CLINICIAN: _____________________________
PRESENT: ______________________________

PATIENT: ______________________________
DOB: _____________  Day: ___  of admission

SUBJECTIVE:
[How patient reports feeling]

OBJECTIVE:
HR: ___  BP: ___/___  RR: ___  Temp: ___  SpO2: ___
NEWS: ___  Fluid balance: ___________
[Relevant examination findings]

ACTIVE PROBLEMS:
1.
2.
3.

INVESTIGATIONS:
Results reviewed: _____________________
Pending: _____________________________

ASSESSMENT:
[Progress, changes, concerns]

PLAN:
Problem 1:
Problem 2:
Problem 3:

Medications changed: ___________________
VTE prophylaxis: ______________________
Discharge plan: _______________________
Follow-up: ____________________________

SIGNATURE: ____________  DATE: _________
NAME (print): __________________________