Transcript Intern_Ward_Indoctrination

Intern Ward
Indoctrination
ACGME’s Core Competencies
• Patient care
• Medical knowledge
• Interpersonal & communication skills
• Professionalism
• Practice-based learning
• Systems-based practice
www.acgme.org
Hierarchy of Values
• Patient care
• Adherence to work hour rules
• Formal education
– Conferences & lectures
– Bedside teaching
– Individual study
Goals and Objectives:
Patient Care
• Interview patients more skillfully
• Define and prioritize patients' medical
problems
• Generate and prioritize differential
diagnoses
• Develop rational, evidence-based
management strategies
Goals and Objectives:
Medical Knowledge
• Expand knowledge of the basic and clinical
•
sciences underlying the care of medical
inpatients
Access and critically evaluate current medical
research that is relevant to the care of
individual patients
Goals and Objectives:
Communication
• Communicate effectively with
– patients and families
– other physicians
– all non-physician members of the health care team
• Present clinical data clearly and concisely, both verbally
and in writing
– H&P’s, progress notes, narrative summaries, etc.
– Rounds, consults, morning report, etc.
• Supervise and instruct medical students, PA students,
nurses, corpsmen, etc.
Professionalism
• Staff will look for…
– Evidence that you…
• have reviewed the chart
• are keeping up with the case & the cases of others on the team
• know the labs, tests, plan, etc.
• are reading independently
– Proper attention to turnover
– Efficiency
– Cleanliness
– Attitude – motivation, being respectful, carrying out all
orders given by staff & residents, maturity
Goals and Objectives:
Practice-Based Learning
• Recognize gaps in personal knowledge and
clinical skills in the care of inpatients
• Develop and implement strategies for
correcting gaps in knowledge and skills
• Improve documentation of medical care
Goals and Objectives:
Systems-Based Practice
• Understand and utilize multidisciplinary resources
to optimize the care of inpatients
• Collaborate with other members of the health care
team to ensure comprehensive patient care
• Use evidence-based, cost-conscious strategies in the
care of inpatients
Work Hours: Rules
NO EXCEPTIONS!
• No more than 80 hours per week, averaged over 4
weeks
• No more than 30 consecutive hours in the hospital
(24 + 6)
• 1 day off in 7, averaged over 4 weeks
– Establish days off today
• No day off earned while on leave or TAD
• YOU ARE RESPONSIBLE FOR REPORTING ANY
CONCERNS FOR GOING OVER YOUR HOURS
– Notify your resident, your staff, and me.
Work Hours: Reality
• ONCE AGAIN -Must adhere to RRC rules!!!
– IM interns – Karen will send out monthly work hour
reports – return these to her
– You will be very inefficient for the first 2-4 weeks
• Before going to sleep
–
–
–
–
ALL
ALL
ALL
ALL
H&P’s must be done
patients must be added to sign out
Narrative Summaries must be started
notes for the following day can be started / outlined
Caring for Patients
• See every patient EVERY DAY
• Check patients’ VS, labs, meds, & TELE EVERY DAY
• Write a progress note every day, including the day of discharge
•
•
•
•
– D/C day can be a brief note
– Write any and all procedure notes – LPs, Blood
Transfusions, etc…
Write a concise narrative summary
Read EVERY CONSULTANT NOTE
Write event notes
Complete notes before rounds
Caring for Patients—
Have some type of method to track patient vitals/meds/labs on daily
basis– see examples:
DATE
•
Name:
Allergies:
BP
PROBLEM LIST:
•
SSN:
•
PCM:
INPT MEDS / Start:
1.
2.
3.
4. DVT Px:
5. CIWA/Banana Bag:
6. Stool Softener:Age:
Pulse
Pox
Temp
HPI:
I/O
IVFS:
PMHx:
Diet
OUTPT MEDS:
Glucose
Na/K
Teaching Venues
• Three conferences per day
• ARRIVE 5 MINUTES EARLY (no scrubs)
– Morning Report at 0800
– Second Half at 0830
– Noon Conference at 1200
• Work rounds with resident
• Teaching rounds with attending
• One-to-one with resident & attending
Event Reports
• Report lapses or problems in care
• Report forms available on intranet
– http://nmcsdintranet.med.navy.mil
• Closely examined and investigated
– Root Cause Analysis (RCA)
Communications
• Notify primary care physician (PCP) via e-mail
that his/her patient has been admitted
– Ultimately the duty of the admitting resident
– DOES NOT INCLUDE NIGHTFLOAT
• Notify nurses of pending discharges
• Write an event note whenever you are asked
to evaluate a patient
Appearance
• No food, drink, or gum during rounds
• Clean lab coat at all times
• Scrubs only when on-call
– After 1600 on weekdays
– All day on Saturday & Sunday
• Men must shave daily
• Women must keep long hair controlled
• Professional attire on weekends
– No jeans, shorts, sneakers, or flip-flops
Consults
• Place Consults as EARLY as possible
• Form consult in a question format – always discuss
•
with resident / staff before consulting
Different Consultants have different procedures:
–
–
–
–
Call all consults via telephone
Speech, PT, Nutrition all require CHCS I entries
Cardiology: Zeke (call fellow’s personal pager)
Derm, Endo, ID, H/O, Neuro, Nephro, Rheum, Surgery : call duty
pager
– GI, Pulm: Call fellow’s personal pager
Labs & Rads
• EKGs: Must be evaluated & signed daily
– TELEMETRY MUST BE REVIEWED EVERY AM FOR OVERNIGHT EVENTS
 yes, every morning!!!
– Ok to use the telemetry phone to call the tech
• Labs:
– Always double check to make sure appropriate labs were drawn
– Stop all unnecessary qday labs
– Verbally tell nurses when any stat lab is ordered
• Rads:
– U/S and CT’s - place Consult in CHCS I as STAT order and place order
“Please contact US/CT tech for pending study”
– Call MRI reading room for MRIs + order CHCS I orders
Medication Reconcilliation
• New JACHO requirement
– Must compare patient’s home medication list
with the current list in AHLTA
– Discharge medication list must be complete
and up to date.
– “How do I do this?”, you ask.
Discharge Summary
• Likely the most important document
during hospitalization
– ALL medications must be clearly listed
– Must have follow-up scheduled with
PCM
Additional Ward Key Points
• Take ownership of your patients – know your
•
•
patients!
IM Wards are NOT shift work
Keep on top of your fellow intern’s patients as you are
responsible for knowing those patients on call and
while covering during days off
– “I don’t’ know because he/she’s not my patient.” IS NEVER
ACCEPTABLE!
• Sign out is key to patient safety
• NO sign out occurs without both residents present!
SIGN OUT – see intern
handbook
Red Team
Staff Pgr
Resident Pgr / Cell / Home Phone
Intern Pgr
Intern Pgr
Patient Info
5N
PMHx & Acute
Illnesses
Current Meds
Current /
Pending
Studies
To Do List
Smith, John
SSN
PMHx:
xxxxxx
Acute Illnesses:
xxxxxxx
XXX
MRI Head
Results pending
CT Head
noncon: neg for
bleed
Blood Cx 7/1,
7/4: negative
LP: cx neg
3 WBC
Protein 50
Glucose 85
-F/U prelim CT
contrast
results (pt at
CT ~1700)
-PanCx (blood,
urine) + CXR if
spikes > 100.4
-F/U Chem
Panel (due at
1800) –
replace K+ if
not = 4.0
-Give Percocet
PRN pain
ONLY
(do NOT give
Demerol)
-EGD / COLO
tomorrow b/c
of xxxx
55 y/o male
admitted for fever
and mental status
changes – likely
aseptic meningitis.
DOA:
Code:
Allergies:
Intern:
SIGN OUT – see pg 28 of intern
handbook
• Inappropriate sign-outs:
– My patient is getting a thoracentesis right now.
• Do we need to check post-procedure labs & CXR? What
do we do with those numbers?
– My patient is altered but don’t worry ‘cuz he’s been
that way for the last 4 days
• What’s the most recent A&O/MMSE/GCS, etc…?
• Why do you think he’s altered?
• What do we do if he becomes more agitated?
SIGN OUT – see intern handbook
• Inappropriate sign-outs:
– The patient has Afib but rate is controlled…
but she may go into RVR overnight?
• What exact regimen do you want us to treat with
– b blocker vs CCB vs digoxin, etc…
• What usually works?
• What max rate of tachycardia are you tolerating?
SIGN OUT – see pg 28 of intern
handbook
• Inappropriate sign-outs:
– Code status is not on the turnover & your
response… “DNI – I think she wants
everything else…”
Additional Ward Key Points
• Each individual resident will have specific
details to add
• When in doubt – check your Intern
Handbook
• For Clinical Questions – read your Clinical
Handbook
Questions or Concerns
• Call YOUR Resident
• Call YOUR Resident
• Call YOUR Resident
Internal Medicine
Homepage
http://nmcsdintranet.med.navy.mil