Medi-Nav Orientation Resource v6, 2024

| 3 3.4.6 Ward rounds It is expected that all inpatients are reviewed regularly and information pertaining to their review is documented in the patient’s medical record. It is every treating doctor’s responsibility to ensure that patient medical record entries are accurate and maintained. Your local orientation program will cover the expectations for participation in ward rounds, including timings, preparation and individual responsibilities. 3.4.7 Attendance in operating theatres and specialist outpatient clinics As a junior doctor, your responsibilities will include attending operating theatre sessions and outpatient clinics. As these services are reliant on complex time scheduling, it is important that you ensure you are punctual or provide early advice if you cannot attend. Please ask your registrar or senior medical officer (as appropriate) to ensure you understand what is expected of you with these timings. Operating theatres have specific dress / infection control requirements, which should be detailed by operating theatre staff as part of your local orientation. 3.4.8 Evidence-based medicine/practice It is your responsibility to ensure that the treatment of patients is evidence-based and best practice. Both evidence-based medicine (EBM) and evidence-based practice (EBP) assert that making clinical decisions based on best evidence, either from the research literature or clinical expertise, improves the quality of care and the patient’s quality of life. Best practice is a comprehensive, integrated and cooperative approach to the continuous improvement of all areas of healthcare delivery. 3.4.9 Documentation Each time you see a patient, you must make a clear and concise entry detailing the presenting problem, history, examination findings and conclusions reached. Healthcare professionals recording in the patient record are responsible for complete and accurate documentation of the clinical judgements as well as care planned and delivered; and for the standard of that documentation. 3.4.10 Referral to specialists and specialist services As a junior doctor, you will be required to write referrals to specialists and specialist services (e.g., diagnostic radiology). Referrals should contain patient details, your site-specific provider number, all relevant clinical information including diagnosis, past surgical/medical history, known allergies and current treatments. Incomplete information will slow down the referral process and ultimately slow down the time to patient treatment. | 29