Ward round note template
The bedside entry made on the round.
- Status
- Stable, improving, deteriorating.
- Overnight events
- The significant ones.
- Examination
- Vitals and a focused examination.
- Plan
- Today's tasks: investigations, medications, consults, mobility, discharge plan.
Worked examples
Ward round note · day 1 post-operative Green, Tanya · 45F · Synthetic patient
Status Day 1 after laparoscopic cholecystectomy, stable. Overnight Settled, mobilised to the chair, analgesia adequate. Examination T 36.9, HR 82, BP 124/76. Abdomen soft. Port sites clean and dry. BS present. Today's tasks Advance diet. Remove IVC if tolerating fluids. Discharge home today if oral intake holds.
Ward round note · day 3 of IV antibiotics Edwards, Phillip · 62M · Synthetic patient
Status Day 3 of IV flucloxacillin for L lower limb cellulitis, improving. Overnight Slept through, one dose of paracetamol for leg pain. Examination Afebrile since yesterday. Erythema receded to the marked line, calf soft, no blistering. Today's tasks Switch to PO cefalexin 500 mg QID to complete 5 to 7 days. Repeat CRP. Venous duplex if calf tenderness persists. Discharge planning with the ward pharmacist.
Ward round note · deteriorating patient Murphy, Agnes · 80F · Synthetic patient
Status Day 5 of an admission for pyelonephritis, deteriorating. Overnight 2 MET calls for hypotension. 2 L crystalloid given. UO 15 mL/h since midnight. Examination BP 88/52, HR 118, T 38.9. Warm peripheries. R renal angle tenderness. Chest clear. Today's tasks Repeat blood cultures. Broaden antibiotics now (meropenem per local guideline), then discuss with microbiology. Lactate now. ICU review for vasopressor support. Urgent CT KUB to exclude obstruction, urology if obstructed. Hourly UO via IDC.
