The Washington Manual Internship Survival Guide (6 page)

•
  Use only approved abbreviations.

•
  Chart patient nonadherence.

•
  Show your thought process.

•
  If you consider something potentially serious and rule it out, say so and why.

•
  Write plans for future treatment.

Don’t

•
  Alter documentation.

•
  Use imprecise terms.

•
  Write negative comments about the patient or family.

•
  Document disputes with other care providers.

INFORMED CONSENT

•
  This includes the type of procedure, reason or indication for the procedure, benefits and risks of the procedure with disclosure of incidence and severity of complications, and explanation of any alternative procedures.

•
  Must be obtained from a competent patient, legally appointed guardian, or durable power of attorney for health care.

•
  When a patient is unable to consent, then consent can be obtained from a spouse, parent, adult children, siblings, or grandparents.

•
  Two physicians can give consent in a life- or limb-threatening emergency.

•
  Must obtain consent of parents or legal guardians for minors.

•
  Minors can consent for themselves if being treated for chemical dependency, STDs, or pregnancy (excepting elective abortion in some states).

•
  It is also important to document informed refusal of a treatment/procedure.

Triage

9

BEFORE ACCEPTING ADMISSIONS

1.
  Obtain demographic information: name, date of birth, medical record number, current location, and attending physician.

2.
  Why does the patient need to be admitted? What is the admitting physician’s assessment?

3.
  Is the patient competent, and does he or she want to be admitted?

4.
  What are the patient’s chief complaints, comorbidities, relevant past medical history, and brief current history?

5.
  When was the last previous admission? Obtain old medical records (inpatient and outpatient). If the patient is coming in transfer, be sure to acquire all radiographs and lab results.

6.
  Obtain most recent vital signs, pertinent examination including mental status, key lab data, CXR, ECG, and code status. Review as many lab results and films in the ED as you can.

7.
  Confirm IV access.

8.
  Inquire about major interventions performed, medications given, and consultations pending.

9.
  What follow-up is necessary (i.e., lab tests that are pending, consults that need to be called, blood transfusions, antibiotics)?

10.
  Find out who the primary physician is and if this person has been notified.

11.
  Do family members need to be called?

OTHER IMPORTANT QUESTIONS TO CONSIDER

•
  Is this an appropriate admission for your service (i.e., Is there something you can do for the patient that no one else can do? Does a different service make more sense?)?

•
  Can this patient be managed as an outpatient? If yes, social services may need to be involved. In addition, arranging follow-up is crucial.

•
  Is the patient stable enough for the floor or for transfer from an outside hospital? Are any more treatments needed before transfer (i.e., nebulizer treatments or blood transfusions)?

•
  Can your staff adequately handle this patient?

•
  What specific interventions does this patient need that other institutions cannot provide (in the case of a hospital-to-hospital transfer)?

•
  Obtain collateral information from family, nursing homes, or other caregivers. Always collect and hold onto important phone contacts.

Admissions

10

GENERAL POINTS

1.
  When called with a new admission, it is critical to review old records. However, if the patient is accessible, always see the patient first and check vital signs before digging through his or her chart. With that said,
old records are invaluable
. Most systems have old lab results, discharge summaries, and H&Ps stored as electronic versions; use these extensively, but always confirm with your own eyes and ears.

2.
  After assessment of the patient and examination,
admission orders should be completed as soon as possible
. This will help the nursing staff and will enable you to get appropriate lab results in a timely manner. If you need stat labs, always inform the nursing staff directly. It is also helpful to inform the nurses when your orders are complete. Telemetry orders should also be completed as soon as possible, if needed.

3.
  Taking a history and performing the physical examination should be well engrained by now. It is often helpful to
type or dictate the H&P right after evaluating the patient before moving on to your next admission
. If you decide to dictate, you must ensure a signed copy of the dictation makes it into the medical record chart.
A short handwritten holding note
of the current admission problems and short assessment should also be entered in the chart while awaiting the dictated H&P. Lab results can be added to the dictation as an addendum.

4.
  If the patient has a private primary care physician, he or she should be notified as soon as possible regarding the admission, and your plan should be communicated to the private physician.
Many private physicians or their covering partners like to be notified as soon as possible
, regardless of the time of night.

5.
  In summary, remember the three pearls of an admission:

•  Assess the stability of the patient immediately.

•  Obtain a good H&P, even if this has already been done by another medical team.

•  Write orders as soon as possible. This makes the nurses and unit clerks happy and allows you to get the lab data you need to finish your evaluation.

ADMISSION ORDERS

•
  Many admission diagnoses have preset clinical pathways and associated order sets (i.e., CHF, asthma), which are often helpful. Also, consider the patient’s eligibility for appropriate research studies.

•
  The mnemonic ADC VAANDISML may be useful:

•  
A
dmit to ward/attending/house officers

•  
D
iagnosis

•  
C
ondition

•  
V
itals: e.g., routine, every shift, every 2 hours. Always include call orders (i.e., call HO for SBP >180 or <90, pulse >130 or <60, RR >30 or <10, T >38.0°C, O
₂
saturation <92%)

•  
A
llergies and reactions

•  
A
ctivity (ad lib, bed rest with bedside commode, up to chair, etc.)

•  
N
ursing (strict I/O, daily weights, guaiac stools, blood sugars, Foleys, etc.)

•  
D
iet (NPO, prudent diabetic, low fat/low cholesterol, renal, low salt, etc.)

•  
I
V (IV fluids, heplock)

•  
S
pecial (wound care, consults with social work, dietitian, and PT/OT)

•  
M
eds: All medications should include dosage, timing, route, and indications. Don’t forget prn meds or you will be called often; if no contraindications, consider including acetaminophen, bisacodyl, docusate, and aluminum and magnesium hydroxide (Maalox).

•  
L
aboratory (including a.m. labs).

•
  Don’t forget DVT prophylaxis for every patient who is not ambulating and GI prophylaxis for critically ill patients (see below for guidelines)!

DVT PROPHYLAXIS

•
  Indications: patients with one or more risk factors for DVT and confined to bed; critical care patients.

•
  Risk factors for DVT: cardiac dysfunction (heart failure, arrhythmia, MI), malignancy, surgery, trauma (especially orthopedic), previous DVT/PE, obesity, smoking, age >40 years, inflammatory disease (e.g., inflammatory bowel disease, lupus), nephrotic syndrome, pregnancy or postpartum within 6 weeks, immobility, acquired/genetic thrombophilia, chronic lung disease, ischemic stroke, serious infections, or indwelling central venous catheter.

•
  Contraindications to pharmacologic prophylaxis: heparin-induced thrombocytopenia; active bleeding; preoperative within 12 hours or postoperative within 24 hours; LP or epidural within 24 hours; recent intraocular or intracranial surgery; coagulopathy.

•
  Recommended regimens (for medical patients):

•  Low-molecular-weight heparin (LMWH): enoxaparin 40 mg subcutaneous qday (adjust dosage for CrCl <30 mg/dL, contraindicated in ESRD) or dalteparin 5,000 units subcutaneous qday.

•  Factor Xa Inhibitor: fondaparinux 2.5 mg subcutaneous qday.

•  Unfractionated heparin (UFH): for patients <100 kg: 5,000 units subcutaneous q8h, for patients >100 kg: 7,500 units subcutaneous q8h.

•  For patients at high risk for bleeding, consider intermittent pneumatic compression or graduated compression stockings.

•
  For planned invasive procedures (e.g., pacemaker placement, catheterization, surgery), hold UFH 8 hours prior to procedure and LMWH 12 hours prior to procedure!

GI PROPHYLAXIS

•
  Gastric erosions and stress-induced ulcers can form in critically ill patients. However, not every patient needs GI prophylaxis—if patients do not have any of the risk factors listed below, prophylaxis is not necessary, even in the ICU setting! Most patients will
not
need GI prophylaxis.

•
  Risk factors for stress-induced ulcers: mechanical ventilation >48 hours, coagulopathy, shock, sepsis, multi-organ system failure, hepatic failure, multiple trauma, burns over >35% of total body surface area, organ transplant recipient, head trauma, spinal cord injury, history of peptic ulcer disease or upper GI bleeding, use of anticoagulants or high-dose corticosteroids.

•
  Recommended regimens:

•  H
₂
blockers: e.g., famotidine 20 mg PO/IV bid or ranitidine 50 mg PO/IV tid

•  Proton pump inhibitors: e.g., omeprazole 40 mg PO qday

ASSESSMENT/PLAN

•
  This is the most important part of your note. It is useful to separate this section by problem. The assessment should include a one-line summary of the patient’s known medical problems (i.e., HTN, T2DM, CAD) and those under evaluation (i.e., fever, melena). For example, 60 y/o female with a history of hypertension, T2DM presents with new-onset chest pain. Include a short differential diagnosis of the current problem.

•
  The plan should be separated by problem. Cover all problems, including stable issues:

1.
  Chest pain: No ECG changes, chest pain free now, will rule out MI, monitor on telemetry, continue ß-blocker, nitrates, ASA, and ACE-I. NPO for stress thallium in AM assuming rules out for MI.

2.
  Hypertension: Good control on current medical regimen.

3.
  T2DM: Good control with A1C of 6.5%. Continue glucose checks, prudent diabetic diet. Hold PO diabetic meds while NPO. Will use insulin sliding scale while NPO.

4.
  Fluids/electrolytes/nutrition (F/E/N): Monitor I/Os, urine output.

5.
  Vascular access: Note patient’s sites of IV access.

6.
  Prophylaxis: Indicate plans for DVT prophylaxis and GI prophylaxis if indicated (see above).

7.
  Disposition: Note any anticipated discharge needs (nursing home placement, home health, home).

8.
  Code status: Code status should be addressed with every patient admitted regardless of age or disease. Unexpected problems arise too often, and it is better to be prepared.

LABORATORY RESULTS AND ORDERS

It is imperative that orders and lab tests are followed up in a timely manner.
You must take personal responsibility to ensure that this is completed
.

PATIENT SAFETY ISSUES

Restraints

•
  Restraints may be needed for patients in a variety of situations. Indications for restraints include the following:

•  Protecting patients from harming themselves (e.g., self-extubation, pulling at Foley catheter, pulling at IV lines)

•  Protecting staff and/or family from patient violence