Medical student ward orientation guide
The ward medical hierarchy
- Consultant - often only visits a few times a week. Makes high level
decisions. The person upon whom patient responsibility ultimately falls.
- Registrar - Senior doctor involved in the day to day management of the
patient
- Intern / Resident - Junior doctors involved in carrying out
administrative tasks hat enable treatment decisions to occur. Good junior
doctors will demonstrate initiative and pre-empt likely decisions that will
be made
Nursing is roughly similar - Clinical nurse manager > Clinical nurse > Senior
RN > Junior RN > Graduate Nurse (GNP) > Enrolled nurse (EN)
Local experience often out-trumps seniority e.g. F/T > P/T or casual
Technically a visiting specialist is a consultant or visiting medical specialist
(VMS) but a full time hospital specialist is a 'staff specialist' (in USA 'the
attending physician or 'attending' versus the 'visiting')
'Service registrar' has the responsibility of a registrar but is not in the
training program.
Sometimes the distinction between senior resident and junior registrar is
blurred
A 'Fellow' is often a twelve month advanced training position for someone either
newly qualified or about to qualify for their specialty. They often get terribly
offended if you accidently call them the registrar. You may make this worse by
calling them the junior consultant.
Ward routine - An example
- 0800 - Morning Handover - from night cover team of overnight admissions
- 0800 - Blood sister round - collects specimens
- 0830 - Registrar round - Registrar review of new admissions and brief
ward round. Review problems overnight. Additional investigations and
management decisions made.
- Mid morning - Scutwork - Intern chases blood results from the morning or
diagnostic studies ordered earlier in the week.
- Later morning - Consultant ward round and consult visits. Registrar (or
interns and residents) presents cases to consultant. Modifications to
management plan made here.
- Lunch break
Early afternoon - More scutwork - interns and residents carry out
instructions. Fluid orders for the next 24 hours. Chart medications. Call
consults for specialist units. Book allied health consults. Organise tests.
- Entire afternoon - Registrar in clinic or theatre
- End of day - End of day round - Check for no outstanding issues. Request
tests for next morning's blood round. Handover pressing issues requiring
follow-up to the evening cover team.
each unit runs slightly differently or even randomly e.g. morning clinics and
theatre lists, afternoon consultant rounds
additional duties include providing specialty consults to other units and
admitting new patients
in the private sector there are no layers i.e. the specialist organises
everything themselves
The ward clinical nurse manager or the registrar usually are able to provide the
weekly routine.
Information required for clinical decisions
- Summary of patients clinical, psychological and social issues (problem
list)
- Diagnostics - e.g. blood tests, imaging studies, endoscopy
- Result of consults i.e. opinions from other specialists
- Types of inpatient management decisions
- Medication - start, stop, change dose
- Fluid orders - rate, type, volume
- Request for specialist consult e.g. cardiology opinion
- Request for allied health input e.g. physio, OT, speech path, OT
- Discharge planning e.g. RDNS, domiciliary home visit, hospital in the
home, respite care, clinic appointments, discharge medication prescription,
GP letters
Specific nursing insructions - 'DAFIT'
- Diet - e.g. diabetic, low protein, low salt, thickened fluids
- Ambulation e.g. ambulate independently, strict bed rest, standby assist
x 2 persons
- Fluid e.g. free fluid, fluid restriction < 1.5L/day,
- Investigation e.g. 4 hrly obs, neurological obs, neurovascular obs,
3x/day Blood sugar, hourly urine output, daily nasogastric tube losses
- Therapy - e.g. medications, oxygen, chest physiotherapy,
Social worker roles (some)
- Accommodation
- Nursing home placement
- Welfare payments / Charity organisations
- Social supports / Support groups
- Community health groups