While you’re still a medical student, there will be few occasions when you’ll make entries in medical records. When communicating with patients, you’ll be supported and shouldn’t be responsible for passing critical information about patients to other healthcare professionals. However, once you qualify, you may need to do this every working day.
Throughout your career you will need to obtain important information from patients, relatives, carers and occasionally even passers-by. It is important to use language and terminology likely to elicit relevant and complete information. The majority of people you will speak to about medical history or information will not be medically trained so it is important to avoid complex medical terms, jargon and abbreviations as these may be misunderstood.
You may need to speak to patients or relatives where there is a language barrier between you. It is important to consider if you need a translator, including British Sign Language (BSL) translators, to support your communication.
When communicating verbally with a patient, relative or carer, avoid giving the impression of patronising those you are speaking to. For example, you should not automatically speak to elderly patients more slowly, using simpler vocabulary and sentence structure if that is not required by that particular patient.
When communicating information verbally to colleagues, for example, during a ward round, ensure you present key details of the history and/or your assessment, emphasising any immediate action needed and summarising what needs to be done. This is a skill often encouraged in junior doctors by consultants – they may ask junior colleagues to summarise a patient’s case to them as part of a post-take ward round for example.
The following fictitious scenario is based on calls and cases dealt with by our advisory team.
What should a medical student do if a patient tells them something that might be important to their care?
A medical student member was invited by an FY1 doctor to practise history taking by talking to a recently admitted patient. The patient was an elderly male admitted with general malaise and weight loss over a period of months. None of the initial investigations had revealed any significant abnormality and although the patient had a complex medical history, nothing explained his presentation and weight loss.
Investigations were ongoing. The member first explained to the nurses what he was going to do and why and checked there was no reason he shouldn’t approach the patient at that time. He then spoke to the patient explaining who he was, clearly stating he was a medical student, not a doctor, and the purpose of speaking to him that day was for his own education. The patient kindly agreed to speak to him.
The member spent a long time discussing the patient’s medical history and then moved on to his social history. The patient explained his wife and two of his adult children lived with him. The member asked if the patient usually needed help with preparing meals, dressing and washing. At this point the patient said he believed somebody in the house might be putting something in his food.
The member wanted to clarify he had understood the patient and asked if he was saying he thought somebody might be putting something in his food which was making him ill. The patient confirmed that was what he was saying. The member completed the history and thanked the patient for speaking to him. The member explained he was concerned the patient’s comment that somebody might be putting something in his food was not one he had shared with anybody else but this could be relevant to understanding why he had been unwell. The patient agreed the medical student should share this information with the nurses and doctors caring for him.
The member rang the MDU advice line. He was concerned as to how best to communicate this information. The medical team caring for the patient was in a meeting and he would be unable to speak to one of them for some time. The MDU adviser suggested the member first speak to a nurse on the ward and pass on the key details of what the patient had said. The MDU adviser suggested the member could leave a voicemail message for the incoming FY1 doctor explaining, in simple terms, what the patient had told him, that he had passed verbal information to a nurse and that he would be making an entry in the records.
Lastly, the MDU adviser advised the member that although he had not been authorised to do so by any doctor, he should make a contemporaneous note in the patient’s records. He did not need to write out the whole history taken. He should document the circumstances in which he came to speak to the patient and the key information the patient had disclosed to him. He should record he had spoken to a nurse (providing their name) and that he had left a voicemail message for a FY1 doctor (also providing their name).
The MDU adviser suggested that on his return to the ward the next day, the member talk to the FY1 doctor to ensure the information had been received and shared with the rest of the team.
Dr Catriona James
Dr Catriona James
Catriona graduated from Glasgow University and trained as a GP in the West of Scotland, before joining the MDU in 2001. Since that time she has completed an LLM in the Legal Aspects of Medical Practice and become a foundation member of the Faculty of Forensic and Legal Medicine. Catriona is based in Glasgow.
See more by Dr Catriona James