Ward rounds
Rounds by voice. Orders on the chart.
The doctor speaks the round at the bedside. Aspataal writes the note and proposes the changes it heard: medicines started and stopped, tests to send. One signature makes them, and the nurses’ drug round follows the chart.
Signing this note will also
- Start Ceftriaxone 1 g IV, twice a dayChart
- Stop Paracetamol infusionChart
- Send CRP tomorrow morningLab
Sign and make 3 changes
One signature, every change in the plan’s own words
Today
Where the time goes today.
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“Orders are written in the file, then copied to the chart.”
Every copy is a chance for a wrong dose or a missed stop.
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“Round notes are short and hard to read.”
The next shift reads the file and still has to ask.
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“The drug chart is behind the doctor’s plan.”
Nurses give what the chart says, not what was decided.
How it works
Four steps, start to finish.
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1
Speak the round
At the bedside, in Hindi or English: how the patient is, and what changes.
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2
Read the note
Subjective, examination, assessment and plan, written up from the round.
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3
Sign the changes
The changes it heard are listed in the plan’s own words. One signature makes them.
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4
The nurses follow the chart
The drug round shows what is due. Vitals, pain, sugar and fluids are charted on each bed’s sheet.
Done for you
What happens without anyone doing it.
- The round note, written up from what the doctor said
- Every change heard, listed in the plan’s own words
- The drug chart updated with what was started, changed and stopped
- Tests from the round, on the lab’s list
- The nurses’ drug round showing what is due now
- The admission note, started from the signed OPD visit
What’s inside
Everything it covers.
Admission notes carried over
The history and examination start from the signed OPD visit.
Orders onto the chart
Started, changed and stopped medicines update the drug chart.
The nurses’ drug round
What is due, what was given and what was held.
Observation charts
Vitals, pain scores, sugar and fluids, on each bed’s sheet.
Other doctors on the case
Doctors also seeing the patient write on the same stay.
Allergies up front
At the top of the stay and of the recording screen.
Works with
Part of one record.
Questions hospitals ask
Do orders change the chart without the doctor?
No. Signing the note lists every change in the plan’s own words and makes them only when the doctor signs.
What do the nurses see?
The drug round from the chart, with what is due now, and the observation charts for each bed.
Can other doctors write on the same patient?
Yes. Doctors asked to see the patient write their own notes on the same stay.
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