It's really important to give complete and accurate information when we pass patients on to other staff or document their care. This helps to make sure that their treatment goes smoothly and that management plans are appropriately followed and executed. In this blog post, we'll talk about why it's so important to do these handovers properly. We'll also look at how to write referral letters that work well, what to do when patients leave against medical advice, and how to write sick notes.

Patient Handovers

It's always really important to handover care of your patients to the on-call team once you finish your shift (or if you ARE the on-call team, then you should handover care back to the day team!). This handover process is important because it helps to ensure appropriate continuity of care and helps to minimise disruption to patients’ management plans.

Here are some things to keep in mind when performing a handover:

• Give all the necessary details - be as thorough as you need to be so that the person taking over knows about any important concerns and can follow up on anything urgent.

• Provide a summary of each patient that includes their name, where they are in the hospital, why they were admitted, and a brief overview of how they've been taken care of so far - mention what has been done and what still needs to be done.

• Clearly communicate any pending tasks or specific actions that need to be taken, such as blood tests or changes in medication.

• Highlight any potential complications or difficulties that have come up, and suggest ways to manage them.

• Share the contact information of relevant healthcare professionals or people who should be contacted in case of emergencies or issues.

• Specify the patient's resuscitation status (if they have chosen not to be resuscitated) or the level of care they need if their condition gets worse.

A really useful mnemonic that will help you perform an effective handover is SBAR:

• Situation: What is the current concern?

• Background: What is the patient’s medical history? Has anything significant happened since admission?

• Assessment: What are the physical examination or investigation findings? How stable is the patient currently?

• Recommendations: What is your impression of the situation? What do you think needs doing? What are you asking for?

Referral Letters

When you need to refer a patient to another team, it's important to communicate your concerns and your requests effectively:

Here's what to include:

• Address the letter to the Consultant of the team receiving the patient (if known)

• Clearly state your name, the name of your Consultant, and your contact information (like your bleep number or ward telephone)

• Provide all relevant patient information (normally this will be on the referral form or already be filled out if doing the referral online - but information to include would be their name, age, sex, date of birth, hospital ID, and where they are currently located).

• You may have to include details of the patient’s GP.

• Clearly state the reason for the referral, including any specific questions or concerns that need to be addressed.

• Include relevant information about the patient's medical history, the findings from the examination, and any recent tests or results that are important.

• Specify the timeframe in which you need the Consultant's advice (if it's urgent), and make sure to ask respectfully.

• Anticipate any tests or information that the receiving team might need, and include them in the referral letter to help speed up the process.

Managing Self-Discharges

Patients have the right to leave the hospital, unless there are serious concerns or they can't make decisions for themselves (i.e. they lack capacity). As a Junior Doctor, it’s important to know how to handle situations where patients wish to self-discharge.

Firstly it’s important to assess a patient’s mental capacity as per the Mental Capacity Act (MCA)- this essentially involves a two-step process:

• Step 1: Determine whether there is an impairment of or disturbance in the functioning of the patient's mind or brain, whether temporary or permanent (remember capacity can fluctuate)

If so, then:

• Stage 2: Is the impairment or disturbance sufficient that, even with all practical and appropriate support, the patient is unable to make a particular decision at the time it needs to be made?

The MCA says that a person is unable to make their own decision if they cannot do one or more of the following four things:

• Understand information given to them

• Retain that information long enough to be able to make the decision

• Weigh up the information available to make the decision

• Communicate their decision – this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand.

In exceptional cases (and I really mean EXCEPTIONAL cases), when absolutely necessary and with guidance from a senior, you can use the Mental Health Act to prevent a patient from leaving against medical advice - this should always be performed under the guidance of an appropriate senior physician.

If a patient does have capacity and they wish to self-discharge then here’s what to do:

• Have an open conversation with the patient, explaining the risks associated with leaving the hospital against medical advice.

• Try to understand their reasons for wanting to leave and see if there are any issues that can be resolved to address their concerns.

• Inform your senior about the patient's decision. If the patient insists on leaving, have them sign a self-discharge note. You can get the note from the ward clerk or write it yourself. Make sure someone else also signs the note as a witness. Include important details like the patient's name, date of birth, hospital ID, and the name of the hospital.

• Document the incident in the patient's medical notes and write to their GP informing them of the self-discharge.

Providing Sick Notes (Fit Notes/MED3)

Sometimes, patients need sick notes to certify that they are unable to work.

In the UK, the traditional sick note was replaced with the fit note in April 2010. This new document allows doctors to provide more detailed information to patients about how their health condition affects their ability to work. By considering various factors, doctors can assess whether a patient is fit for work in general, which helps them make informed decisions and eventually return to work when appropriate. Let's look at the purpose of the fit note and how doctors should approach it.

Purpose of the Fit Note:

• The fit note is meant to inform patients about how their health condition affects their ability to work. It aims to help individuals return to work by considering their specific circumstances and any necessary adjustments.

When completing a fit note, doctors should consider the following factors to make an accurate assessment:

• Functional Limitations: Evaluate any limitations caused by the patient's health condition. This can include stamina, mobility, agility, insight/stability, treatment requirements, intellectual abilities, and sensory functions like hearing, vision, and touch.

• Duration and Fluctuation: Consider how long the health condition lasts and whether it fluctuates over time. Understanding these aspects helps determine the appropriate period for which the fit note should be valid.

• Impact of Clinical Management: Take into account how ongoing clinical management, like treatments or therapies, affects the patient's ability to work.

• Worsening Condition: Assess whether doing any kind of work, not necessarily their current job, would make the patient's health condition worse. This information helps determine if they are fit for work.

Completing the Fit Note - here are some guidelines for properly completing a fit note:

• Check the box that accurately describes whether the patient is "not fit for work" or "may be fit for work" based on their diagnosis and your assessment of their condition and current health status.

• Specify the duration of the fit note. For the first six months of a patient's condition, the fit note can cover a maximum of three months. If the condition has lasted for more than six months, the fit note can be issued for any appropriate period, even an "indefinite period."

• Provide advice in the free text section of the fit note. Use this section to offer guidance about how the patient's health condition affects their ability to work. This allows you to provide specific advice tailored to their situation.

• Use the tick boxes to give an overview of the factors your advice covers. This reinforces the functional limitations that are relevant to the patient's condition.

• If possible, limit sick leave provided on the fit note to a maximum of two weeks. After this period, advise patients to consult their GP for further sick notes or a re-evaluation of their condition.

The fit note is a helpful tool for patients to understand how their health condition affects their ability to work. By considering functional limitations, duration, clinical management, and potential exacerbation of the condition, doctors can provide accurate assessments and guidance. Completing the fit note involves checking the appropriate box, specifying the duration, providing advice in the free text section, and using tick boxes to summarise the patient's condition.

Conclusion

Effective patient handovers, clear referral letters, proper management of self-discharges, and accurate provision of sick notes are all crucial for efficient healthcare. By following these guidelines and best practices, doctors can improve patient safety, promote collaboration among healthcare teams, and streamline communication.

by Dr Ahmed Kazie