Transcript Documentation - Emory University Department of Pediatrics

Orientation to the Pediatric
Emergency Medicine Rotation
Children’s Healthcare of Atlanta
@ Hughes-Spalding
Welcome!
 The Pediatric Emergency Center (PEC) & Pediatric Urgent
Center (PUC or “Walk-In”) offers a unique opportunity to
participate in the care of sick and injured children.
 The spectrum of disease & variations in severity is
unmatched in any other pediatric rotation.
 You will be directly managing patient care under the
supervision of a faculty member of the Division of Emergency
Medicine in the Department of Pediatrics of Emory University
School of Medicine.
2
This Orientation
 General Expectations
 Nuts n’ Bolts of your shift
 Trouble shooting: where to turn when
challenges arise
NOTE: This orientation is an introductory overview. All
learners must review the resources found on our website
under “Teaching Portal”:
www.pediatrics.emory.edu/divisions/emergencymedicine
3
Expectations

What to expect of the faculty
(attendings and fellows)
 What the faculty expects of you
4
Expectations of Faculty
Faculty will:
 give you the opportunity to examine,
assess and present patients.
 assess your patients and provide feedback
on areas of agreement and disagreement.
 explain their recommendations and
decisions.
5
Expectations of Faculty
cont’d
Faculty will:
 teach and supervise procedures.
 provide feedback to you on perceived
strengths and weaknesses during the
rotation.
 provide end of rotation evaluation.
6
Expectations of the Learners
(outline)






7
Before you begin the rotation
Attendance
Dress Code
Professional Behavior
Documentation
Patient Care
Expectations of the learners:
Before you Begin
Obtain your schedule
 www.amion.com. Password: emupeds
Activate your name on the Teaching Portal
website:
www.pediatrics.emory.edu/divisions/emergencymedicine
 Donna Stringfellow should be emailing your login/password
to the Teaching Portal prior to the start of your rotation
 [email protected]
 (404) 785-7142
 Review/complete all pertinent material and links:
Orientations, PreTest, Learning Modules
8
Expectations of the learners:
Before you Begin
 Make sure the following have been
arranged by your program coordinator:
 Parking
 ID Badge
 Computer access to Grady “Citrix” & “Ultra C”
9
Expectations of the Learners
(outline)






10
Before you begin the rotation
Attendance
Dress Code
Professional Behavior
Documentation
Patient Care
Expectations of the learners:
Attendance
 Begin on-time (your peers are waiting!)
 Find coverage for unexpected schedule
conflicts and clear it with your
program/chief resident
 Notify your program/chief resident of
special requests > 3 months in advance
 Follow your schedule: make sure you are in
correct location (i.e. PEC vs PUC)
11
Expectations of the Learners
 Before you begin
 Attendance
 Dress Code
 Professional Behavior
 Documentation
 Patient Care
12
Expectations of the learners:
Dress Code





Business casual
Scrubs OK (well-fitting, clean and fresh)
No open-toed shoes, artificial nails
No denim, capris, or hem-line above knee
No short blouses, low necklines, tight clothing
Please refer to CHOA/Emory guidelines for more details:
•
•
CHOA Policy 4.11
www.med.emory.edu/GME/house_staff_policies_section25.cfm
Above all, be neat and presentable!
13
Expectations of the Learners
 Before You Begin
 Attendance
 Dress Code
 Professional Behavior
 Documentation
 Patient Care
14
Expectations of the learners:
Professional Behavior
 Confidentiality
• non-healthcare providers should not be able to hear
discussions with & about patients
 Respectful
• Interact courteously with families & staff
 Sensitivity to length of stay
• update your patients ~ every 30 min, even if brief
 De-escalate tension
• Approach potential or actual conflicts in a constructive
manner
Please refer to the Family Centered Care power
point for more complete guidance!
15
Expectations of
the learners




Before you begin
Attendance
Dress Code
Professional Behavior
 Documentation
 Patient Care
16
Expectations of the learners:
Documentation
Completion of the chart:

History and Physical

Impression & Reassessments

Order Page

Procedure note

Respiratory Orders

Medication Reconciliation

Discharge Instructions

Disposition: condition & time
17
Documentation:
History & Physical
Date & Time
Chief Complaint
Targeted HPI
Relevant ROS
Past Med/Fam/Soc
Physical Exam with
available Vital
Signs (includes
pain & weight)
Legible signature
18
Documentation:
Impression
 Document your
assessment
including a
differential
diagnosis list.
(This is key for
presenting the case
and helping others
understand what you
were thinking!)
19
Documentation:
Reassessments
 Who to reassess:
All patients with orders,
interventions or abnormal
vital signs.
 Examples of what to
reassess:





20
Pain
Respiratory distress
Abnormal vital signs
Alertness
Ability to take PO
 Time each reassessment!
 Write down lab results and
radiology readings.
 Write down d/w consults.
Documentation:
Order Page
 Initial & time each
order
 Initial & legibly sign
in designated
space
 Use separate
Physician Order
sheet for:
 pharmacy orders
 extra orders
21
Documentation:
Procedure Note
Examples:




Splints
Laceration repair
Incision & Drainage
Lumbar Puncture
Not required:
 Pelvic exam
 Flourescein study
Remember to date, time, and
legibly sign your note!
22
Documentation:
Respiratory
 Respiratory Orders
 Fill in date, time,
weight
 Initial & time each
order
 Initial & legibly sign
in designated space
 Reassessments:
 Condition
23
 Date & Time
 Initials & legible
signature
Documentation:
Radiology
 Select desired test
 Pt sticker on each
page
 Indicate reason for
test
 Sign, date order
• Include PIC or callback
number
 For CTs: call to put
pt on Grady CT list.
24
Documentation:
Medication Reconciliation
 Review and sign on
presentation: note
date & time
 Review and sign on
discharge: note
date & time
25
Documentation:
D/C Instructions – Rx
 LEGIBLE
 Include allergies &
weight
 Note concentration of
suspensions
 Doses in ml (not mg)
 Sign & print name, NPI
#, DEA # (if
applicable) & date
 Cross out unused Rx
lines
26
Documentation:
Discharge Instructions
 LEGIBLE
 Avoid medical
jargon
• (5th grade reading level)
 Useful information:
 Appropriate follow-up
(default: call PCP’s in the
morning)
 Criteria for return
 Appropriate handouts
 Review with
discharging nurse if
possible
27
Documentation:
Discharge Time & Condition
Review & sign :
 Condition on
discharge
 Disposition Time
 Disposition
Location
28
Expectations of the Learners





Before you begin
Attendance
Dress Code
Professional Behavior
Documentation
 Patient Care
29
Patient Care: Day #1
 Try to arrive 15 minutes early on your first shift
 Introduce yourself to the attending and let them
know it’s your first day
 You will have an orientation with one of the nursing
staff
30
How-To care for patients
in the Pediatric Emergency Department
Identify yourself to the attending, staff
Identify next patient to be seen
Perform and document history & physical
Present case to attending, fellow or charge
resident
Place orders (magnet system)
Monitor status of orders
Reassess patient (and document)
Make final disposition
31
Step 1:
Identify yourself to staff
 Who am I?
• name, year of training
 Where am I supposed to be and when?
• PUC vs PEC (check hourly schedule posted in
MD workroom)
• shift you are working
 Write your name, shift, location (PEC vs PUC),
on the designated board
32
Step 2:
Identify next patient
Look for patients on board without a
physician assigned (yellow magnet)
 Check “time to room” for longest waiting
 See EMERGENT patients first (blue or red
magnet by complaint, e.g. sickle cell with pain/fever,
respiratory distress)
Look for charts in circular rack @ the
central nurses station
Apply patient labels to History & Physical
Exam form
33
Step 3:
Perform and Document H&P
You are representing the attending
Identify yourself to the patient and family
Explain process
Professional behavior
H&Ps in the ED are more focused and should
take less time than in-patient H&Ps.
Most assessments should take < 10 minutes.
34
Perform and Document H&P:
Team Approach to Care
 Nursing staff also complete initial evaluation on patients
• May occur simultaneously with physician evaluation
• If a nurse is in the room: ok to enter the room, introduce
yourself & ask them if you may start your evaluation
 Be polite: do not interrupt, ask that they stop their
assessment or leave the room.
 COOPERATION & TEAMWORK are the goals
 Patient Access staff may be interviewing your patient
briefly: wait for a break in the conversation and ask if it is ok
for you to begin your interview
• PAS staff understand families are there to see the doctor
and do their best to work around us
• Remember: patients have to be registered!
35
Perform and Document H&P:
Caregiver initiated protocols
 Nursing /ancillary staff have standing protocols to start
care for certain patients
• Asthma
• Sickle cell pain & fever
• Vomiting
• LET (topical anesthetic) to lacerations
• Analgesics
 You can interview families/obtain history while IV is
placed, labs are drawn, or breathing treatments given
 Ask the nurses or RCPs where they are in the process if
you have questions
 Remember: We share the chart – put it back where it
belongs!
36
Step 3:
Perform & Document H&P (cont’d)
 Non-English speaking families
• Must use qualified medical interpreter (staff or
language line) when historian has difficulty
understanding questions due to language
barrier
• Ask your attending or charge RN for language
line phones.
 Students may document only on the following
aspects of the patient chart:
 Review of systems
 Past Medical/Family/Social history
37
Step 4:
Present the case
 Seek out the attending, fellow or charge
resident to present your case ASAP.
 Begin with the chief complaint: why are they here?
 Often this isn’t clear until the end of your encounter!
 Parent chief complaint & our primary concern may not be the
same.
 HPI should be focused with a succinct
summary of the quantifiers and qualifiers of
relevant symptoms (e.g. duration, severity, frequency,
quality)
38
Step 4:
Present the case (cont’d)
Summarize the case briefly (should be able to do
in 1 breath!)
Present Differential Diagnosis with rationale
 Most likely & Most serious conditions
 Not a laundry list
Present your Plan with rationale
NOTE: This is where the learning is at!
39
Step 5:
Place orders (see slide 20)
 Write clearly, using only approved
abbreviations
 Special order forms:
• Respiratory orders (slide 22)
• Radiology orders (slide 23)
 include your pager #!
• Pharmacy orders (meds not available in ED)
 include patient weight & allergies!
40
Step 5:
Place orders (cont’d)
Magnet System
Orders to be completed
41
Financial Counseling
Respiratory Orders
Discharge
Needs to be seen
Admit
Step 5:
Place orders (cont’d)
 Place red magnet on the board for nursing orders.
 Tell the RN for the patient about the orders.
 CT scans & ultrasound: call Grady to place patient on list.
 Unit clerk will use ASCOM phone to notify RN of order.
 Place blue magnet on board for respiratory orders
 Tell the RT for the patient about the orders (the unit secretary
will call them on their ASCOM)
 Place chart with orders in rack in front of unit clerk.
42
Step 6:
Monitor status of orders
Were orders were taken by nurse?
 check chart
 ask nurse
Check to see if the lab has received
specimen (UltraC)
 call the lab for results if none in the
computer after 30 minutes.
Call Radiology for special studies:
ultrasound, CT
 call for CT results if haven’t heard from
radiology in 30 minutes.
43
Step 7:
Monitor Status of Patient & Document
Document a reassessment after any
intervention (slides 19, 22):
 breathing treatment
 fluids
 medications
e.g. : If you don’t document that a dehydrated patient took PO
and improved during their ED visit then it will appear as if
you sent home a dehydrated patient!
44
RETURN CHART TO DESIGNATED PLACE
IN CIRCULAR RACK AT CENTRAL
NURSING DESK AFTER USE!
Step 8:
Final Disposition (see slide 27)
Discuss with attending, fellow or charge
resident
Remember an attending (or overnight fellow)
must see all patients!!
Patients without a final disposition at the
end of your shift should be signed out to
another resident
45
Step 8:
Final Disposition: Admitted Patients
 Admitted patients need
 sign-out to admitting resident (404) 225-1969
& document
 bed sheet w/ accepting attending & “obs” vs
“inpatient” status
 give completed bed sheet to charge nurse
46
Step 8:
Final Disposition: Home
 Patients discharged from ED need
Completed Medical Reconciliation form
Completed Discharge form
 meaningful advice
 note handouts provided
Documented time and condition at discharge
Green magnet on the board (chart completed)
47
Tips for positive encounters
Establish a good relationship
 Make eye contact, smile, use their name, sit!
 Give your title & explain your role in the department
Prove you have heard them
 Summarize what they tell you
 Discuss the plan of care with them
Set time expectations
 Tell them when they can expect to see you again
 TIP: Overestimate the time
 Explain delays
Answer questions
48
 verify understanding
 solicit regularly
Additional Patient Care issues
 Clean hands before and after every patient
encounter
 Patients without insurance should be
offered financial counseling
 Turn around time goal: 139 minutes
49
Charge Resident
 Senior pediatric resident identified when
possible for each shift
 Functions as “junior attending”
 attention to patient flow
 attention to sickest patients
 Precepts and supervises students and
junior residents (including procedures)
 Makes arrangements for admissions
50
Trouble shooting:
Scheduling Questions
I have a conflict with a scheduled shift. What should I
do?
 Alert the Emory peds chiefs and Dr. Patel via email.
Can I take vacation time during my rotation?
 Vacation requests should have been submitted to YOUR
program chiefs 3 months in advance.
I’m sick and can’t work my shift. Who do I call?
 Call your fellow residents (to switch shifts) and the
Emory peds chiefs. If you can, call the ED also and
apprise them of the situation.
51
Trouble shooting:
Evaluation Questions
Who is my PEM program coordinator?










52
Emory Pediatrics: Dr John Cheng
Emory Emergency Medicine: Dr David Goo
Morehouse Pediatrics: Dr Taryn Taylor
Morehouse Family Practice: Dr Tiffany McKinnie
Emory Transitional Residents: Dr Mike Ziegler
Emory Psychiatry: Dr Debbie Young
Emory Family Practice: Dr Debbie Young
Emory School of Medicine (MS4): Dr Mike Ziegler
Emory Nurse Practitioner Students: Dr Tracy Merrill
Emory Physician Assistant Students: Dr Mike Ziegler
Trouble shooting:
Schedule contacts
 Emory pediatrics chief residents
 www.amion.com
 Password: emupeds
 Select “PEC” at the top
 Select appropriate block with arrow buttons
 Chief resident emails are at bottom of PEC schedules
 Dr. Roshni Patel
 [email protected]
53
Trouble shooting:
Working Environment Questions
How can I address challenges in working
relationships with different members of the
healthcare team?
 Approach them directly when you can
have an uninterrupted conversation in
private
 Discuss your concerns with the attending
54
Have a great rotation in the
Pediatric Emergency Department!
55