Resident education through patient care Medicine, whether as a primary care physician or specialist, is driven by patient care. In whatever capacity residents will practice in after residency they will undoubtedly admit, care for and discharge in a hospital setting. During residency residents have a limited time to learn as much as they can about practical patient care and should realize that the more patients that they admit, round on, and discharge the better they will be able to face the realities of medicine today. Interns should have seen all their patients prior to morning report or rounds. You may not have completed notes on all of them but as long as you have laid hands and eyes on them to be sure that they are stable you are doing alright. If they aren't stable call someone...like your senior resident.
Basics of pre-rounding Review vital signs for the past 24 hours with the goal of predicting or identifying SIRS and shock as well as initiating appropriate measures for the same. All abnormal reported vital signs must be rechecked with the appropriate equipment by the resident. Included in this is:
Review telemetry with the goal of treating dysrhythmias and determining the necessity of telemetry. Check the preprandial blood sugars with the goal of adjusting IVF and insulin for adequate glycemic control. Assess volume status by reviewing serial weights as well as input and output.
Review diagnostic testing, identifying and tracking disease based on serial diagnostic assessments of stress, hemostasis, electrolytes, and metabolism. Improvement, worsening, and stability of results must be addressed in progress notes and orders. Included in this is adaily review of culture and sensitivity results. Remember to interpret screening tests in the context of active disease.
Perform a progress note review, in this address concerns of nursing staff as well as review specialist recommendations and order if necessary.
Perform an order review
This is in addition to thorough patient interview and focused physical exam.
Taking ownership for patient care Make sure that nursing, ancillary and house staff know that this is your patient. This is fostered by face-to-face conversation regarding plan of care with the staff. If there is a method for recording your name as the primary contact for patient care make sure you do it. Make sure there is a clear communication regarding coverage and transfer of care should this be necessary.
Floor pages Your pager is always on and you always answer in under 5 minutes. Period. If you start with this attitude you will be amazed at how infrequently you will get paged, as the staff learns how easy it is to get a hold of you they will only page you when they actually needyou.
Safe discharge planning Discharge planning starts with admission to the hospital. An accurate home or ECF medication list should be obtained at admission and be correctly reflected in the EMR. Do not trust that the list in the EMR is correct unless you have personally verified this with the patient. If you think the patient will need rehabilitation or ECF placement order PT/OT evaluation early and review their notes. While the patient is admitted remove Foley's as early as possible, too often discharge is complicated by iatrogenically induced urinary retention. Review the need for telemetry daily as well. Reducing unnecessary interventions and monitoring moves patients toward discharge. Review medications daily and implement the appropriate changes, so that dosing changes the day after discharge do not send the patient straight back to the ED. Get case management involved as soon as necessary by speaking to them personally. This may be as simple as concerns about transport to as serious as setting up home oxygen or hospice care. Review specialists notes for documentation of desired follow-up and follow-up testing. If this is unclear, page the specialist in question and ask. Know if and when a patient needs a PICC or a midline for continued IV therapy. On discharge there are some key things that need to happen:
Discharge summaries need to be prompt and accurate. They must be completed within 24 hours of discharge. At a minimum they should include:
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