Introduction
As a Foundation Year 1 (FY1) doctor, you will write 10, 20, or even more ward round entries every single day. It’s the most common task you’ll perform, and it’s easy to become complacent. But a bad, vague, or illegible note—or a “job” scribbled on a post-it—is a major clinical risk. The patient record is the primary source of truth for the entire multidisciplinary team, and a failure in documentation is a failure in communication and patient safety.
This guide provides a structured, 5-step method for how to document a ward round effectively. This is not just admin; it’s a procedural skill. Mastering it ensures your notes are a clear, safe, and legally-sound tool that protects your patients, helps your colleagues, and demonstrates your competence as an FY1.
Key Takeaways
It’s a Legal Document: The primary rule of medical documentation is: “If it’s not written, it didn’t happen.” Your notes are a legal record of care.
SOAP is the Gold Standard: The Subjective, Objective, Assessment, Plan (SOAP) framework is the gold standard for structuring a clear and comprehensive entry.
The “Plan” is the Point: The “Plan” is the most critical part of your note. It is the “jobs list” and communication tool for the entire multidisinplinary team.
Always Sign Off: Every entry, no matter how small, must be clearly dated, timed, and signed with your name, grade, and GMC number.
Why Mastering How to Document a Ward Round is a Core Safety Skill
Learning how to document a ward round is a non-negotiable patient safety skill. Vague notes lead to missed tasks, medication errors, and poor handovers.
“If It’s Not Written, It Didn’t Happen”: The Legal Standard
Your patient notes are a legal and professional record of care. In a complaint or a coroner’s investigation, your documentation will be your only evidence of what was observed, assessed, and planned. The Royal College of Physicians (RCP) emphasizes that clear documentation is essential for high-quality, safe care.
“Good documentation is not a luxury, it is a legal and professional requirement. It is the basis for communication and continuity of care.”
— Royal College of Physicians
A Tool for Communication and Continuity of Care
Your note is not for you; it’s for everyone else. It’s read by:
Senior doctors (to review the plan)
Nurses (to action obs, medications, and fluid balance)
Pharmacists (to review prescriptions)
Physiotherapists (to check mobility status)
The on-call team (who will read it at 3 AM)
A clear note ensures everyone is working from the same, accurate plan, which is a key part of professionalism and patient safety.
How Clear Documentation is Assessed in the UKMLA
The UKMLA CPSA assesses your ability to function as a safe FY1. While you may not be marked on writing a full ward round note, you will be assessed on the skills that go into one: clear record-keeping, safe prescribing, and effective communication. An examiner in a handover or referral station will be looking for the same structured, logical thinking that goes into a high-quality SOAP note.
The 5-Step Method for Perfect Ward Round Documentation
Step 1: Prepare (Review Notes, Obs & Results Before the Round)
Never start a ward round “cold.” Arrive 15-20 minutes early to “prep the list.” For each patient, quickly review:
The overnight handover notes.
The observation chart (NEWS2 score, trends).
Fluid balance chart.
New investigation results (bloods, imaging). This preparation is what allows you to contribute to the round and write an accurate note.
Step 2: Actively Listen & Record (During the Round)
You are the scribe. Your job is to be the ears of the consultant and the hand that records the plan.
Stand next to the consultant or senior registrar.
Write in the patient’s notes at the bedside (if using paper) or on the mobile computer.
Record the consultant’s Assessment and Plan verbatim. Do not try to interpret or shorten it until you are confident.
If a plan is unclear (e.g., “Review bloods”), ask for clarification: “Sorry, what specifically are we looking for and what action should we take?”
Step 3: Use the SOAP Framework for Structure (S, O, A, P)
SOAP is the gold standard for a reason. It is logical, comprehensive, and easy for anyone to read and find the information they need.
Step 4: Write the “Jobs List” (The Actionable Plan)
The “Plan” section of your SOAP note is the jobs list for the day. Make it a clear, numbered list of discrete tasks.
Bad Plan: “Chase bloods, review antibiotics, for OT.”
Good Plan:
Check FBC & U&Es at 1 PM.
If K+ > 5.5, stop Ramipril and re-check in AM.
Refer to OT for functional assessment.
Antibiotics: Day 3/5 of IV Co-amoxiclav.
Step 5: Sign Off (Date, Time, Name, Grade, GMC Number)
Every entry must be legally attributable to you.
Date: 05/11/2025
Time: 09:30 (Use 24-hour clock)
Signature: [Your Signature]
Print Name: DR. JANE SMITH
Grade: FY1
GMC No: 1234567
The SOAP Framework: Your Gold Standard for Every Entry
This is the core of how to document a ward round.
Table 1: The SOAP Framework Explained
| Letter | Stands for | What to Write |
|---|---|---|
| S | Subjective | What the patient says. “Feeling better today.” “Chest pain is gone.” “Opened bowels.” “N/V” (Nausea/Vomiting). |
| O | Objective | What you find. Obs (Temp, HR, BP, RR, Sats). Exam findings (“Chest: clear”). Fluid balance. Key results (“Na 135, K 4.1, Cr 88”). |
| A | Assessment | Your clinical judgment. “Clinically improving.” “Resolving pneumonia.” “New AKI Stage 2.” “Patient is medically fit for discharge (MFD).” |
| P | Plan | The “jobs list.” A clear, numbered list of actions. “1. Continue IV Abx.” “2. Chase CT scan.” “3. Refer to Physio.” |
As the Royal College of Surgeons guide on good practice states, documentation should be clear, contemporaneous, and provide enough detail for another professional to take over care.
A Gold-Standard Example: What to Write
This is what a high-quality, safe, and legal ward round entry looks like.
What to Write: The Gold-Standard Ward Round Entry
05/11/2025 – 09:30 – Dr. [Consultant’s Name], Consultant [Specialty] (Scribed by: Dr. J. Smith, FY1, GMC 1234567)
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S:
Patient reports feeling “much brighter.”
Cough is less productive. No chest pain.
Ate 50% of breakfast.
Opened bowels yesterday.
O:
Obs: T 37.1, HR 88, BP 115/70, RR 18, O2 Sats 96% on 1L. NEWS2 = 1.
Exam: Chest has mild crackles at R base, no wheeze. Abdo SNT. Calves SNT.
Bloods: WCC 10.1, CRP 45 (down from 120 on admission). U&Es normal.
Fluid Balance: -500ml over 24h (good diuresis).
A:
Resolving community-acquired pneumonia, good clinical and biochemical response to IV antibiotics.
Ready to step down to oral therapy.
Plan for discharge tomorrow if remains stable.
P:
Abx: Stop IV Co-amoxiclav. Start oral Co-amoxiclav 625mg TDS (to complete 5-day course).
Meds: Continue all regular meds.
Fluids: Stop IV fluids. Encourage oral fluids.
Discharge:
Plan for discharge tomorrow (06/11).
Write TTOs (discharge meds) for tomorrow.
Inform patient and family.
Escalate: If new fever > 38.0 or O2 sats < 92%.
[Signature] DR. JANE SMITH, FY1, GMC 1234567
How to Structure Your “Jobs List” for the Team
Your “Plan” becomes the source for your personal “jobs list” and for your handover. When handing over, you can use the same structure. For more, read our SBAR handover tool guide.
Table 2: Common Ward Round Documentation Pitfalls (Dos & Don’ts)
| Pitfall | Why It’s a Problem | How to Fix It |
|---|---|---|
| ✗ Using Unsafe Abbreviations | “MTX” or “AZA” can be misread. Using “U” for units can be fatal (e.g., “10U” looks like “100”). | ✓ Write in full. “Methotrexate.” “Azathioprine.” “10 units.” Check this guide to **[UK medical abbreviations](https://ukmlaquestionbank.com/uk-medical-abbreviations-for-imgs/)**. |
| ✗ Vague “Plan” | “Chase bloods.” “Continue.” “Review.” This is meaningless to the on-call team. | ✓ Be specific. “Chase FBC at 2 PM. If Hb < 80, transfuse 1 unit.” “Continue IV fluids at 125ml/hr.” |
| ✗ No Time/Date | A legal and safety nightmare. No one knows when the entry was made or if it’s the most recent one. | ✓ Always start** with Date (DD/MM/YYYY) and Time (24h clock). |
| ✗ Scribbling/Illegible Writing | Illegible writing is a medication error waiting to happen. It is unprofessional and dangerous. | ✓ Use clear capitals. If your handwriting is poor, print your entry. This is non-negotiable. |
Putting It Into Practice: 2 Clinical Scenarios
Scenario 1: The Standard Medical Patient (Pneumonia)
S: “Feeling brighter, cough improved.”
O: “NEWS2=1. T=37.1. CRP down to 50. CXR improving.”
A: “Resolving CAP. Ready for oral step-down.”
P: “1. Stop IV Abx. 2. Start oral Doxycycline 100mg OD (5-day course). 3. Plan for discharge tomorrow.”
Scenario 2: The Complex Surgical Patient (Post-Op AKI)
S: “Tired. Feeling sick.”
O: “NEWS2=5 (low BP, high HR). BP 90/50, HR 110. Urine output 20ml/hr. Cr 180 (up from 90 pre-op). Abdo soft, drain 50ml.”
A: “Post-op Day 2. AKI Stage 2, likely 2/2 hypovolaemia.”
P:
Immediate: 500ml STAT bolus of Hartmann’s.
Meds: Hold Ramipril. Hold Metformin.
Monitor: Strict fluid balance (hourly urine). Repeat U&Es in 4 hours.
Escalate: Inform senior (surgical registrar) immediately.
How Ward Round Notes Build Your Discharge Summary
Your daily “Assessment” and “Plan” entries become the “Clinical Narrative” for your final discharge summary. A good set of ward notes makes writing the discharge summary a 10-minute job.
Your Turn: A Self-Assessment Exercise
Scenario: A 50-year-old man is on Day 2 of IV Flucloxacillin for simple cellulitis of his right leg. He is apyrexial. The leg is less red. He is eating and drinking. The consultant says, “He’s doing well, we can switch him to oral antibiotics and aim for discharge today.”
Your Task: Write the “Assessment” and “Plan” (A/P) sections for this ward round entry.
Model Answer:
A:
Improving cellulitis, good response to IV therapy.
Apyrexial, NEWS2=0.
Clinically well, ready for oral step-down.
Medically fit for discharge (MFD).
P:
Abx: Stop IV Flucloxacillin. Start oral Flucloxacillin 1g QDS (10-day course total, 8 days remaining).
Discharge: Plan for discharge today.
TTOs: Write TTOs (oral Flucloxacillin).
Patient: Counsel on finishing Abx course and red flags (e.g., fever, worsening redness).
Frequently Asked Questions (FAQ) about how to document a ward round
Do not scribble it out or use correction fluid (Tipp-Ex). This is illegal and looks like a cover-up. The correct legal way is to draw a single, clear line through the error so it is still legible. Write the correct entry next to it and initial and date the change.
You will always forget things. To add a late entry (e.g., a blood result you checked after the round), start a new entry. Write the current date and time, and title it “Late Entry” (or “Addendum to ward round note at [time]”). Then write your note, e.g., “15:00 – Late Entry: 14:00 FBC result: Hb 90. Plan: Transfuse 1 unit as per plan.”
This is a common pitfall. Some abbreviations are safe and universal (e.g., “CXR,” “FBC,” “BP”). Many are dangerous and should never be used (e.g., “U” for units, “MTX” for methotrexate). The rule is: when in doubt, write it out. A good guide is the list of common UK medical abbreviations.
The principles are identical (SOAP, clear plan, sign off). Electronic notes have advantages (they are legible, time-stamped, and remotely accessible) but have their own risks. The biggest risk is “note bloat” or “copy-paste,” where entries are copied from the day before, including old plans. This is dangerous. Always write a new, fresh assessment and plan every day.
Your note should be concise but complete. It needs to tell the story of the day.
Too little: “S/O – Well. A – Stable. P – Cont.” (This is a useless, lazy note).
Too much: A full-page essay copying every blood test and the patient’s entire life story.
Just right: The gold-standard example above. It focuses on the active problem, the response to treatment, and the plan for the next 24 hours.
Yes. Every patient on the ward must have a consultant-led review and a corresponding note at least once every 24 hours. For very stable, long-term patients, this may be a simple “A – Stable, P – Continue current plan,” but it must be documented. Unstable patients will need multiple entries per day.
The FY1 doctor who scribed the note is traditionally responsible for ensuring the “jobs” in the “Plan” are actioned (e.g., writing the TTOs, making the referrals, chasing the bloods). This is why a clear, numbered list is so important—it becomes your “to-do” list for the rest of the day.
You must ask for clarification at the bedside. This is a critical safety step. It is your GMC number on the note. If you write a vague plan like “Review antibiotics” and a medication error occurs, you are also responsible. Ask: “Sorry, by ‘review antibiotics,’ do you mean we should stop them or switch to oral?”
This is a senior-led decision and must be documented with extreme care, usually on a specific form (e.g., a ReSPECT form). The ward round note should state: “A/P: Patient has been reviewed by [Consultant]. ReSPECT form completed for DNACPR. This was discussion in full with [patient/family]. See ReSPECT form for details.”
The principles are the same, but the focus is on safety and holding. The plan should be extra clear for the on-call team.
“Plan: 1. Stable for weekend. 2. No specific jobs. 3. For senior review on Monday.”
OR: “Plan: 1. Unstable. 2. Please re-check U&Es on Sunday AM. 3. If K+ > 5.5, please call on-call renal registrar.”
Conclusion
Learning how to document a ward round is a procedural skill, just like taking blood or suturing. It is the backbone of inpatient care, good communication, and your own legal protection. It is not “just admin”; it is a critical task that ensures the entire team knows the assessment and plan.
By following the 5-step method—Prepare, Record, SOAP, Plan, and Sign Off—you create notes that are clear, efficient, and safe. This builds trust with your colleagues, protects your patients, and proves you are a competent, professional, and safe FY1 doctor, ready to write the all-important discharge summary that your notes will build.
Your Next Steps
Find a good example: Ask a registrar or clinical pharmacist on your ward to show you an example of a “gold-standard” ward round entry.
Practice the “Plan”: For your next few notes, focus entirely on making your “Plan” a perfect, numbered list of actionable, specific jobs.
Time yourself: See if you can apply the SOAP framework to a stable patient in 2-3 minutes to build efficiency.
Read the standards: Review the RCP’s guidance on ward rounds to understand the high-level principles of good practice.
