--- module: 046-01 language: en chapter: 46 title: "Integrated Ward Presentation, Handover, and Longitudinal Care" module_title: "Foundations" source_sha256: b621ddebbe1a94b463d1d54f1b533eb4fe9da7bb33f4a4edc02f9ac3847edfea --- # Integrated ward presentation, handover, and longitudinal care ## Orientation and first contact ### Converting incomplete information into safe action #### Threats, representation, ranking, tests, treatment, revision ### Ward care coordinates people, shifts, settings ### Handover preserves reasoning and future tasks ### Treat physiological threats before full history #### Normal pressure does not exclude shock ### Confirm identity, allergies, pregnancy, decision support ### Record pre-intervention state #### Treatment response distinguishes mechanisms ## Problem representation and problem list ### One sentence: context, tempo, syndrome, severity ### Qualifiers: acute, focal, inflammatory, progressive ### Negatives only if reliable and discriminating ### Avoid premature labels, update with new data ### Separate syndromes, diagnoses, complications, barriers ### Merge duplicates, preserve causal relationships ### Rank by threat, reversibility, time, patient priority ## Differential diagnosis ### Built from anatomy, mechanism, tempo ### Likely, dangerous, and patient-specific causes #### Long unranked list is not safer ### Evidence for and against leading possibilities ### Stable patient: diagnostic time can be therapeutic ### Irreversible risk: immediate empirical action ### Treatment failure: revisit alternatives ## Investigation strategy ### Each test has a defined purpose ### Predict how each result changes action #### No change in action: reconsider testing ### Good specimens before treatment when safe ### Verify unexpected results ### Critical findings by closed loop #### Recipient, meaning, action, escalation ## Treatment plan and therapeutic trial ### Written around goals and mechanisms ### Drug, dose, route, interval, review, stop conditions #### Another clinician can continue safely ### Trial needs target, time frame, alternative #### No response: wrong diagnosis, delivery, disease, time ### Balance benefits over different horizons #### Avoid hypoglycaemia over intensive control #### Held preventive drugs need restart review ## Medication reconciliation ### Pre-admission use vs current and discharge orders ### Multiple sources: patient, pharmacy, primary care ### Differences intentional or unintentional #### Omission, duplication, wrong concentration #### Kidney adjustment failure, harmful restart ### High-risk: anticoagulants, insulin, opioids ### Held medicines: reason and restart criteria #### Unexplained list transfers ambiguity ### Confirm access, affordability, dexterity, cognition ## Ward review, escalation, and uncertainty ### Review trends, intake, devices, results, response ### Per problem: status, action, monitoring, escalation ### Concern overrides a reassuring score ### Escalate when physiology worsens or setting fails #### Urgency first, then context and specific request #### Persist through hierarchy if unsafe ### Grade uncertainty: known, likely, dangerous #### Safety-net: observation, thresholds, follow-up ### Diagnostic error: anchoring, premature closure #### Pause: what else, what does not fit ## Handover and documentation ### Lead with action-critical information ### Task: what, why, when, owner, expected, abnormal ### Closed-loop questions and restatement ### Unresolved danger communicated directly ### Notes timely, factual, attributable, useful ### Separate observation, reports, inference ### Describe behaviour without judgement ## Discharge and longitudinal care ### Planning begins at admission ### Stability: safe outside current monitoring ### Pending tests with owners, warning symptoms ### Teach-back and accessible written information ### Address cause and predisposing conditions ### Multimorbidity: benefit, burden, goals #### Coordinate specialists across organs ### Rehabilitation and social support are treatment ## Shared decisions, goals, and safety learning ### Options, outcomes, uncertainty, burdens, values ### Resuscitation decision covers arrest only ### Palliative care alongside disease treatment #### Intensify comfort, not abandonment ### After harm: stabilise, disclose, preserve evidence ### Standardisation and design beat education ### Just culture: error, shortcuts, recklessness