Resident/Intern/Medical Student Internal Medicine inpatient Tipes/information/expectations:
1) H&P: Should be dictated and presented to attending in the following order: CC, HPI, PMH/PSH, Medications, Allergies, SH, FH, ROS, Physical Examination, Labs and diagnostic tests, Assessment, Plan, Code status.
2) Discharge summaries: Should be done within the same day or the latest, within 24 hours after discharge. If intern or resident off on that day, they should plan to cover for each other and get this done.
3) Notes:
a) Either do not do any abbreviations or if so, do only standard universally acceptable abbreviations. If you are not sure, do not abbreviate. Some example of unacceptable abbreviations that we have seen used: bf for boyfriend, prob for probably, dced for discontinued, and many others.
b) Pay attention to punctuations in your notes. Good grammer, although sometimes can be bypassed, is important to follow for more clarity of notes and also for medico-legal reasons.
c) Pay attention to the case (upper vs lower) of the letter you use. For example HgbA1C should not be written as hgba1c.
d) Verify and make correction to the notes that you have dictated (i.e. consults, discharge summaries, H&Ps) ASAP. This way the attending will be able to read your note and only make corrections that he/she thinks you have not been able to make yourself. This will help reduce the work of the attending and also give you a chance to present your work better to your attending.
e) All progress notes should be finished and signed by the resident/intern prior to midnight of the day that the patient was seen.
4) Code Status: Patient’s code status should be asked at time of doing H&P and should be mentioned on the H&P (best place is at the end of PLAN) and an order should be placed for this. If the patient cannot make a decision about this, then a next of kin or guardian should make this decision and if they are not available, then the patient is full code till either the patient can make that decision or the next of kin or guardian becomes available to do so.
5) Nutrition: Pay attention to your patient’s nutritional status. Start tube-feeding or TPN/PPN early. Nutrition has a lot do to with the patient’s outcome.
6) Last bowel movement: This is frequently forgotten about because it is not asked about and patients are very often shy about bringing it up. Try to remember to ask the patient about bowel movements on daily basis. Also do not forget to order a bowel regimen on all patients that are on narcotics.
7) Urine output: Hospitalized patient are at much higher risk of going into renal insufficiency than outpatients and usually the first sign of renal insufficiency is decrease in urine output. Pay close attention to this.
8) Daily weights: This is important in a lot of patients on the internal medicine service but not all the patients. Daily weights are a more accurate assessment of patient’s fluid status from day to day than measuring ins and outs. This is because it is frequently difficult and time-consuming for the nursing staff to measure the ins and outs on the patients.
9) DVT prophylaxis: Every patient that comes to the hospital should be considered for DVT prophylaxis. Pulmonary embolism is a major cause of hospital related mortality and it can be prevented with good DVT prophylaxis measure.
10) GI prophylaxis: A lot of patients that are admitted to the hospital (especially if on steroid, not eating, tube-feeding, sepsis, stressful illness, use of NSAIDs, on Coumadin or Plavix) should be considered strongly for GI prophylaxis. This can be done by a PPI or a proton pump inhibitor.
11) Ambulation: It is a proven fact that if the patients do not ambulate and are bed-bound, they don’t do as well and they will not be discharged as quickly as patients who do. It is therefore essential to write orders for physical therapy as early as it seems necessary and also to write orders for nursing staff specifying that the patient should be ambulating at least several times a day. Often if such orders are not written, the nursing staff will not do that since they are short on time.
12) IV fluids: Pay attention to rate and duration of IV fluids on daily basis. Very frequently patients go into CHF in a hospital setting because someone forgets to decrease the rate of IV fluids or discontinue them especially when patients start eating and drinking on their own. On the other hand, do not forget to start a patient on IV fluids while they are NPO for a procedure or test. Also pay attention to the electrolytes in the IV fluids; these may also need to be modifies on daily basis.
13) IV antibiotics: IV antibiotics can often be changed to oral depending on the patient’s illness and medical condition. Pay attention to this and switch as early as possible.
14) Pain control: Pain-control is a big issue in hospitalized patients. It is very important that one understands the use of pain meds and knows if the pain medications provided are either too much or too little and try to modify them as needed. Also know how much pain medication and anti-anxiety medication your patients have used in the last 24 hours when you are presenting the patient on the rounds.
15) Treat the patient’s clinical picture and not the numbers. For example, WBC could be trending up from 12 to 15 but the patient may be feeling better. This usually does not require change in treatment, but rather close follow up with the patient’s clinical picture.
16) Before ordering any labs (or diagnostic tests), think if the patient really needs that ordered and think if the results of that lab (or diagnostic test) would make you change your plan. If your plan does not change, then it is very likely that you do not need to order that. Also remember that most laboratory and diagnostic tests have a false-positive percent associated with them and therefore if you order things that are not necessary, you will end up ordering other things to see why a false-positive test was abnormal.
17) Try to put your orders in as soon as possible and especially talk to consultants as early as possible in the day. This will likely shorten the length of stay of the patient in the hospital.
18) Consult your social worker and case manager on all patients that may need their help prior to weekend. This may require some careful planning and thinking from your side about the patients for coming or existing needs before the weekend comes. This also can make a big difference on the patient’s length of stay in the hospital.
19) Get social work, speech/swallow, and PT/OT involved early to help expedite discharge.
20) Order home O2 the day before discharge to expedite discharge.
21) Start writing post-call day notes on call day (but do not sign till finished on call day) to save time on call day.
22) Write anticipated discharge orders the day before if you have time to help save time the next day; you never know how busy you will be the next day.
23) Befriend nurses, they can really help, or hinder you.
24) Discuss 24 hour events with nursing before rounds and discuss plans with nursing staff after rounds. In general, keeping the nursing staff informed about the patients results on decreased length of stay and better care of the patient.
25) Always think of disposition of the patient. This should be as part of the daily note for the patient. Always ask what is keeping the patient in the hospital and what you can do to help resolve that so that the patient can be discharged.
26) All team members should attend all educational functions (morning report and noon conferences) and try to be on time. For a list and time of these events, contact the education office.
27) Make sure that the discharge medications in Powerchart are accurate. Medications should be explained well to the patient prior to their discharge home. The patient’s should have a clear understanding of why and how they are taking each of their medications, why a pre-hospital medication was discontinued, and why a new medication was started. This increases compliance and decreases errors. Make sure the medications are accurately reflected in Powerchart since this is the list that will be placed on your discharge summary.
28) Check MARS everyday and change, add, or discontinue medications as needed. Very often, a medication that was started will be forgotten to be discontinued on a timely manner unless one is paying close attention to MARS everyday.
29) Everyone on the team should know all patients on the team to help cover.
30) Contact attending with any major changes in a patient’s condition or for unexpected patient death.
31) Patients’ list on the computer must be maintained with accurate information every day. This is essential for proper sign out.
32) Contact your attending at the end of the working day to give him a summary of the events since you met last. This should be done by the resident. On the day that resident is off, this is done by the intern.
33) All intern and resident notes need to be co-signed by the attending. This includes progress notes, discharge summaries, and H&Ps. Please forward these to the correct attending as you complete typing or dictating your notes.
34) Progress notes should be typed in the Powerchart “clinical notes” section and should not be dictated. Pay attention to copy and pasting your notes from one day to the next. You need to make sure that the vocabulary, grammer, and other things in the note are edited to conform to that day’s events, treatments, plans, exam, etc.
35) All patients being discharged must have follow-up and PCPs should be contacted with updated information.
36) Every patient’s treatment/intervention/study should be discussed with the patient during rounds.
37) Enter all nursing, lab, or medication errors on Patient Safety Net. This is essential for quality improvement.
38) Try to avoid verbal orders when possible and when you do verbal orders make sure to have the nurse repeat the order back to you to make sure she has heard you right.
39) Be careful about copying and pasting your notes. If you do so, you have to make sure you read the body of the note carefully to make sure that the vocabulary/grammer is changed in such way that it would reflect that day’s note, not previous day’s.
40) When you are answering a page back, once the person on the other side picks up the phone, you should state your name, the team you are presenting, and that you have been paged (e.g. hi, this is Dr Jones, the resident on the Blue Internal Medicine Team, I was paged to this number).
41) Whenever possible, try to be precise in your orders to avoid misunderstanding and confusion. This will save time and help expedite care of the patients and therefore decrease length of hospital stay as well as preventing medical errors.
42) Try to get medical records from other facilities early on during the care of the patients by having the patient sign a release of information on the first day of admission. Also in your orders request that you be called once the records are available.
43) Whenever possible, try to talk to PCP shortly after or during the time of discharging the patient to let him know about the important things.
44) About ROS.
45) Make sure discharge summaries medications are consolidated correctly.
46) Explain the medications to the patient before discharge.
47) Do the progress notes the same day.
48) Edit the H&P as soon as possible.
49) Protocol all the tests as early as possible. The following things do not need to be protocoled:
PET CT’s.
Ultrasounds.
CT of the head without contrast.
PT/OT consults.
50) Interns and Medical students should call the resident on the team first with any questions or concerns. The resident then decides if he/she can handle this on his/her own or if needs to call the attending for help.
51) H&Ps and Consults must be dictated immediately upon completion.
52) Checkout: Thorough checkout is important. It is the responsibility of the resident to check out to the cross-cover resident at 7pm. On the days that the resident is off, the attending will do this task.
53) Team Pager: It is extremely important that the team pager be carried by the resident or intern at all times and that it be answered in a timely manner.
54) It is your responsibility to arrange coverage for your patients with residents, interns, or attending on your days off.
55) The resident is considered to be the team leader. All issues should be brought to him/her first and not the attending unless he/she is off that day or not available.
56) Interns and medical students should confirm patient’s plan with the resident before rounds.
57) The resident should check all orders placed by interns and medical students especially on new admissions.
58) All consults are done by the resident and then presented to the attending. As of now, the ward team’s resident that is on call on that night will do the consults for that day.
59) Hem-onc patients should be presented to Hem-onc fellow and attending post call morning.
60) Interim summaries should be completed on all patients before transferring off ward service.
61) For medical students, a typed H&P should be turned to attending on the post-call day.