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Resident and Intern Inpatient Expectations

Page history last edited by Kali Graham 8 months, 1 week ago

Also see Inpatient Service Main Page for goals/objectives/competencies (in right sidebar under IPS links)

 

Pre-Rounding (6am-9am)

  • Come in between 6am-6:30am every day (remember you need to have 10 hours off between shifts). In the first few months of the year, new interns should plan to come in at 6am as they work on clinical efficiency. Ask night float if there are any urgent issues. Many labs may not be available this early so use this time to see your patients and get organized. This first hour (before 7am signout) should be used by pre-rounders to prioritize seeing patients who are sick or unstable.
  • If patients look concerning, ask the resident/attending to see the patient during this time. 

 

Teaching and Sign out (7:00-7:30am)

 

Morning Report (7:30-8:00am)

  • Attending arrives at 7:30am, night team presents patients who were admitted overnight
  • Finish by 8:00 to be on time to meet with case management

 

Finish Pre-Rounding (8:00 to 9am)

  • Start notes, call consults, start discharge processes, follow-up labs -> make plans to advance patient care.
  • Make sure ALL patients are seen by 9am. If you need more time consider arriving earlier or asking your resident/attending for help with efficiency. 

 

Rounding (9am-12pm)

  • Interns: Present to the senior resident, be detail-oriented. Learn the basic plan of care for all patients on the team
  • Residents: learn to manage a team: keep rounds moving, give input to interns/sub-I’s and help them formulate care plans
  • Rounding style will vary by senior resident/attending but should include both walk rounds on good bedside learning cases and table rounds.
  • If you are not presenting, try to put in orders for your peers.   
  • VTE Prophylaxis: many pts should be on prophylaxis meds (not just SCDs or ambulation). If not on meds, make sure it's been discussed
  • Those presenting patients should know the amount of prn medications (ativan, morphine, etc.) patients received in the last 24 hours (look in the MAR) 
  • Be especially aware of these issues: IV fluids, foley, VTE prophylaxis, blood sugar readings, code status, cardiac monitoring (is it needed?)
  • Our goal is to average >50% of all discharge orders entered by 1pm. 
  • Notes should be done by 12:30pm or before leaving for clinic or didactics  

 

1pm Educational Sessions and Core Didactics

  • Please see Inpatient Education Conference Schedule for details  
  • Residents are responsible for some of the talks - please reference the link for details.  Please make sure you look for your assigned day at the beginning of your month. 

 

Note Writing

  • Progress notes should be done and sent to attending for signature by 12:30pm at the latest.  
  • Progress notes tend to have too much old information in the assessment/plan section.  If you want to carry forward some information on inactive issues, please use something like a "stable issues" section. Conditions you are actively treating (i.e.: Diabetes with AC/HS blood sugar checks and insulin titration) are not "stable issues." 
  • Do not copy and paste entire assessment/plan sections from the day before. Also, no need to cut/paste the radiology read, culture sensitivities, etc.  Those are already in the computer.  Same goes for consultants' recommendations.  Summarize these.

  • In general, progress notes aren’t needed the day of discharge, as long as you add a section into the DC summary "Physical exam on day of discharge."

  • Senior resident to see all new admission consults and talk through the plan with the intern before the intern staffs the patient with the attending 

  • Senior residents and attendings share the responsibility to contact the patient’s PCP (email/phone) every time a pt is discharged, or something else important clinically happens (transferred to the MICU, passes away, etc.). This is the responsibility of the senior resident, with help from the attending. 
  • Medical Student progress note process:
    • Senior residents need to review and cosign medical student progress notes (with appropriate attestation) prior to sending them to the attending to sign --see separate page
    • PA and NP students have different expectations found here
  • If there is a billing query, residents should addend their note to answer the query. Please reach out to attending if there are any questions about how to answer the query. 

 

Daytime Admissions

  • The day call senior resident is in the tiger role for FM admissions at 7am.  If they get far behind on admissions (i.e. 3 new pts waiting to be seen), they should ask the other team to take a patient. We don't want patients to wait to be seen by our team too long.
  • Admissions/ICU transfers should be done as soon as possible, but sometimes they will need to be handed off.  Prepare appropriately for handoffs by prioritizing what needs to get done before shift change.
  • Please use FM Adult Admitting Criteria to guide admission decisions, but any discrepancies should be handled on an attending-to-attending level.
  • H&P must be completed at the time of admission and DC Summaries must be completed within 24 hrs of discharge, preferably at the time of discharge. 
  • Please make sure every pt has an admitting diagnosis listed 
  • Put the daytime team attending down on admission orders and electronic ED bed request form. 

 

Discharges

  • More and more, we recognize that the discharge day is a critical time for patient care.  Much of the good of what we've done during the hospitalization can be undone without proper attention to detail.  A few tips:     
  • On day of discharge, do "discharge rounds."  Instead of the "SOAP" presentation, go over DDEMAP
    • D – Diagnosis: discharge primary and secondary diagnoses
    • D – Destination: where they are going and transportation
    • E – Equipment: home health or equipment needs, home O2
    • M – Medications: paying attention to chronic medications that were discontinued and new medications 
    • A – Appointments: all follow-up appointments
    • P – Pending: labs and studies to be followed after discharge 
  • These things should also all be put in the discharge summary.  This is key information and needs to be accurate. 
  • Try to discharge patients as early in the day as possible.  If you know a patient can be discharged the next day, get their information ready so they can be discharged early, perhaps even writing a "dc" order during rounds. 
  • With few exceptions, the resident who discharges the patient should do the discharge summary, even if that person was just rounding on the weekend.  In situations where the patient is very complex, the residents can decide together that a resident who is not present that day will do the discharge, but this should be discussed directly between the involved residents, to make sure there is no unintended miscommunication. If the discharge summary will be done by a resident who is off that day, it needs to be done within 24 hours, and the discharging physician should write a progress note for the day of discharge (so we have a documented encounter for that day).

 

Care Transitions

  • We work closely with the inpatient pharmacy, working on making sure medications are correct on both admission and discharge. 
  • Here's what you need to know how to do:
    1. Medication reconciliation on admission
    2. Read "Care Transitions" notes that are done by pharmacy, and make sure to note that it was reviewed in the daily progress note 
    3. On discharge, contact the "PCAP" (a pharmacist): 264-6970. 7 days a week.  They will review meds looking for discrepancies.  This isn't necessary if the patient is only on one or two medications.
  • For CHF discharges you MUST talk with the CHF pharmacist prior to discharge to review the medication reconciliation 
  • For facility transfers (ie: SNF) the transfer document is found in the depart process and must be done prior to discharge. To do: in the "depart process," click on pencil next to "DC Instr/Follow Up." Then type "hospital" in the search box and choose the one that says "discharge to other facility orders." Then fill that out.

 

Getting the Work Done

  • Pay particular attention to the discharge med reconciliation process- people have been sent home on dangerous duplications of medications.  Tip: look at the med list the patient will get before they go (it prints out).
  • Residents perform consultations from other services. If we need to keep following the patient, they should be seen primarily by the resident. 

 

End of Day Sign-Out (7p-7:15p)

  • Resident: check in with your attending at about 5 daily so we can run the list, think about overnight “to-do’s”, think about who will be DC’d tomorrow, etc. (some attendings will have a different preference for how they like to be contacted)
  • Resident: Ensure good sign out is done by the team, by discussing sign out with the intern if they will be signing out the team.  Also, help coordinate how sign out will occur during the weekend to optimize continuity.
  • Non-admitting team: If work is done and patients are stable you may leave at 5pm after you signout to admitting day team. Senior resident then calls night float resident after 7pm for telephone sign-out.
  • Admitting team: Signout directly to night float at 7:00pm. Both Intern and Senior are expected to stay until sign-out.
  • A key to good signout is updating the main diagnosis on the list if a dx has been made. (replace "64 yo F with SOB, DOE, CP" with "64 yo F with PE" if she has a PE)
  • Use IPASS system for sign-out, prioritize sickest patients first when you are signing out.
  • Keep the CACHE list up to date on your patients
  • See separate sign out/in page for more info

 

Overnight Call Communication

  • If a patient with acute and unanticipated decompensation overnight that requires an event note, the attending should be notified
  • If a patient dies overnight, the attending should be notified
  • If we are consulted for admission and advise the ED that the patient can be discharged, the case should be run by the on-call attending to make sure they agree with not admitting the patient 

 

Duty hours

  • We adhere strictly to duty hour regulations, which were put in place for reasons of patient safety.  Our largest risk for violations with our current schedule is the "10 hours off" between shifts.  Staying late- as much as it might be done for reasons of dedication, is viewed by GME and our department as putting patients in unsafe situations.  
  • The late day intern and resident leave right after signout, which occurs 7:00-7:15pm.   The day team then leaves- don't save work for after signout.  The late day team should start preparing to sign out tasks at 5:30.  Admissions after 5pm (if patients are stable) will often need to be signed out for the night team to complete and present to attendings.  From 5-7:00pm, the day team is often in a mode of "triage" where they are attending to the immediate needs of sick patients, and preparing for the transition to the night team.  If you feel patient care is being compromised,  call the attending who can help prioritize the work, or even come in to help if needed. 
  • If you feel like you are having consistent trouble leaving in time to have 10 hours off on late shifts, please tell one of your attendings or residency leadership.  

 

Professionalism

  • Both teams should work together to optimize our resources.  The better we work together and utilize our resources, the better care we can offer.
  • Be on time for rounds and educational conferences. Conferences start promptly @ 1:00pm, so stop rounding and get food before noon. 

 

Overnight

  • for more info about the roles of the night people- please see the separate Night Float expectations
  • Our general goal is to keep team A and B the same in terms of census.

 

Caps/Saturation Protocols, etc

 

Misc. Tips and Policies

  • Multi-disciplinary rounds: 8:00am for team A and team B. At least a resident and/or PA should attend, but the more attendees, the better.
  • Resident School attendance:  All levels of residents are expected to attend from 1:00-4:00pm.  APPs and attendings will help to cover. You are expected to come back to service after resident school unless told otherwise. 
  • Only write for PPI’s when there is a clear indication- not just “GI prophylaxis.” (this may increase risk for Cdif and HCAP).
  • Appropriate levels of care and monitoring: about 25% of pts in UNM on cardiac monitors meet criteria for cardiac monitors (in a recent survey). Remember "Floor Status" is a billing differentiation and can include telemetry monitoring.  
  • Interim summaries should be done on patients before transferring off the ward service for patients who are complex and have been in the hospital for more than 48hr.

  • Residents should make sure everyone is on the same page in regards to the team schedule (days off, clinic, etc)
  • Co-following: Residents co-follow sub-interns, PAs co-follow PA students   
  • Order home Othe day before discharge if possible, get appointments and medications ready on Friday for anticipated weekend discharges.
  • With all patients, talk to nurses about 24 hour events, concerns, etc, before rounds. Please keep them in the loop on the plan for all patients.
  • Please be aware of the continuity policy regarding patients who have a resident PCP
  • Residents answer billing queries, reach out to attending if you have questions about how to answer the query 

 

Days off

  • look here to see the appropriate schedule to see when your days off are. 
  • Senior resident days off are on the weekend day that their team is listed as the admitting team.  Interns and residents are not allowed to trade out of their weekend rounding days when on the rotation for patient continuity reasons- except in emergency cases.

 

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