The Washington Manual Internship Survival Guide (8 page)

•  O
₂
sat <88% on room air consistently (at rest, with exercise, or with sleep).

•  PaO
₂
of 55 to 59 mm Hg or O
₂
sat <89% with evidence of cor pulmonale or secondary polycythemia (Hct >55%).

•
  Discontinue Foley catheters, sitters, telemetry monitoring, and supplemental oxygen as soon as possible. Many rehabilitation facilities require that these are not present 24 hours before discharge.

•
  Change antibiotics and diuretics to PO the day before discharge. Avoid a.m. lab work the morning of discharge, unless absolutely necessary.

•
  Provide prescriptions for a 1-month supply of all medications, excluding controlled substances unless absolutely necessary.
Reconcile discharge medications with admission medications
. Make a note in the discharge summary of the patient’s current medication list as well as any medications that were discontinued or dose-adjusted during the admission. This paperwork can often be done in advance.

•
  
Dictate the discharge summary at the time of discharge
. It may seem painful at the time, but it will save you time later and prevent frustration on outpatient follow-up. It is most efficient to dictate when you are most familiar with the patient and hospital course. Take the extra 5 to 10 minutes to complete it now.

•
  The hospital course section of a well-organized discharge summary is generally organized by problem list.

DISCHARGE SUMMARY

Each institution has its own rules on discharge summaries. However, most should include the following items:

•
  Your name, the attending physician’s name, and patient name and medical record number.

•
  Date of admission and discharge.

•
  Principal and secondary diagnoses and procedures.

•
  Chief complaint, HPI, and allergies.

•
  Hospital course, including all major events, listing of major radiological and diagnostic tests and results, and all major therapeutic interventions.

•
  Discharge medications, diet, and activity. Again,
make sure to reconcile admission and discharge medications and ensure that your dictated list is correct
. Errors in this regard are a major cause of unanticipated outcomes and readmissions.

•
  Follow-up plans, including dates and times of outpatient appointments/studies.

•
  Condition on discharge.

•
  Copy distribution. Be sure to include any physicians outside your healthcare system who do not have access to your electronic documentation.

Cross-Coverage

13

GENERAL POINTS

•
  For the first few months of residency, whenever you are called about a patient, go examine them, review the chart, and assess the situation. Communicate your impression and plan with the nursing staff and write a brief event note in the chart. Continue to do this until you feel comfortable deciding what situations can be adequately handled over the telephone with the nurses and the support staff.

•
  
If there is any doubt, see the patient. The patient is always your number one priority.

•
  Once you have seen the patient, write an event note (this can be brief, depending on the situation). Things to document include the following:

•  The reason you were called to see patient (e.g., CTSP for chest pain).

•  A summary of the situation. This includes the patient’s general appearance, vitals, pertinent physical examination, pertinent laboratory, and imaging data.

•  A synopsis of your plan. This includes all medical decision making such as diagnostic tools you ordered and medications provided.

•  Outcome.

REASONS YOU MUST GO SEE A PATIENT

•
  Any major changes in clinical status:

•  Altered mental status or other changes in neurologic state

•  Dyspnea

•  Chest pain

•  Severe abdominal pain

•  Seizures

•  Uncontrolled bleeding (hemoptysis, hematemesis, lower GI bleed, hematuria, vaginal bleeding)

•  Intractable vomiting

•  Severe headache

•  New onset of pain

•  Falls

•
  Any major changes in vital signs:

•  Oxygen desaturation

•  Hypotension

•  Arrhythmias (tachyarrhythmias and bradyarrhythmias)

•  Fever associated with changes in mental status, changes in other vital signs

THINGS TO CONSIDER OBTAINING BEFORE ARRIVAL AT BEDSIDE

•
  
If the nurse’s summary of the patient sounds unstable or you are at all unsure, page your resident immediately!

•
  Full set of vitals

•
  Hospital chart at bedside

•
  IV access

•
  Oxygen (nasal cannula, face mask), respiratory therapist

•
  Cardiac monitor, ECG

•
  Crash/code cart

•
  Chest X-ray

•
  ABG kits

•
  Blood cultures, if febrile

•
  Basic lab results

THINGS THAT CAN WAIT

•
  Talking to family members; unless urgent, this can usually be handled by the primary team.

•
  Major adjustments in medication regimen in a stable patient (i.e., antihypertensive medicines, antibiotics).

•
  Consultations in nonemergent, stable situations (i.e., GI consult in patient with occult blood-positive brown stool, stable hematocrit, stable vital signs).

•
  Addressing code status in a stable patient. This is best addressed by the patient’s primary medical team.

APPROPRIATE TRANSFER OF PATIENTS TO THE INTENSIVE CARE UNIT

•
  Determine which unit is most appropriate for management of the patient.
Do not hesitate to incorporate your resident into the decision making process.

•
  Speak to the resident who will be accepting the patient to inform him or her of the situation and provide sign-out.

•
  Have the nursing staff give report to the staff in the unit.

•
  Write a brief transfer note that includes the following:

•  When and why you were called to see the patient

•  One-line description of patient and his or her comorbidities

•  Your assessment of the situation

•  Your management of the situation, including diagnostic and therapeutic measures, complications, and outcome. Include code note, if appropriate

•  Your assessment and plan with brief differential diagnosis for what could be going on

•  Reason for transfer (e.g., hypotension arrhythmia, unstable vital signs, closer monitoring)

•  Vascular access (e.g., femoral line, peripheral IV)

•  Code status

•  Who has been notified and their contact information (patient’s physician, family members)

Other Notes of Importance

14

OFF-SERVICE NOTES

It is your final day on the wards, you’ve had a grueling month, and the last thing you want to do is write yet another note, let alone think about writing long, drawn-out off-service notes. However, the presence of concise off-service notes can be a lifesaver to the intern coming onto the service. The essentials include the following items:

•
  Date of admission

•
  Any new diagnoses/alterations in previous diagnoses

•
  Pertinent past medical history

•
  Hospital course (major interventions, events, procedures); this can be organized chronologically or by organ system depending on the patient. This is not a day-by-day recap of every test performed. Distill the story down to its essential details

•
  Current medications including day number for antibiotics

•
  Current pertinent PE and lab results

•
  Assessment and plan, including goals of care and discharge needs (skilled nursing facility placement, home IV antibiotics, etc.)

PROCEDURE NOTES

These are of vital importance as part of the documentation of the hospital course and should include the following items:

•
  Procedure, site of procedure. Regulatory bodies now require documentation of a pre-procedure “time-out” to confirm the patient’s name and procedure performed

•
  Indication(s)

•
  Informed consent

•
  Sterile prep used

•
  Anesthesia used

•
  Brief description of the procedure

•
  Specimens and what they were sent for. Of note, any fluids that you just spent your valuable time collecting should be hand delivered to the lab personally

•
  Complications

•
  Post-procedure disposition and pending follow-up studies (e.g., CXR post-central line placement)

DEATH/EXPIRATIONS

Interns are called on quite frequently to pronounce a death. Certain steps must be performed:

•
  On arrival to the bedside, you should observe for respirations, auscultate for heart sounds, palpate for a pulse, and attempt to elicit a corneal reflex. You also need to agree on an exact time of death with the nursing staff.

•
  Notify your attending physician, the private physician, and family immediately, even in the middle of the night. The family must be asked specifically about (1) autopsy, (2) anatomic gift donation, and (3) funeral home. Appropriate forms for an autopsy and anatomic gifts must be completed.
Note: Many hospitals have specially trained personnel to handle these particular requests, so be aware that it may not be appropriate for you to approach the family regarding these issues. Notify the appropriate hospital personnel if necessary.

•
  Complete a death note in the progress note section of the chart. It should include the following information: “Called by nursing to see patient regarding unresponsiveness. The patient was found to be breathless, pulseless, and without heart sounds, blood pressure, and corneal reflexes. The patient was pronounced dead at 9:55 p.m. on August 29, 2012. The patient’s private physician and family were notified. The patient’s family refused both anatomic gifts and autopsy. The funeral home will be Manchester Mortuary.” The word
dead
must be used.

•
  The Certificate of Death must be completed, including your assessment of cause of death. If the patient has a private physician, the death certificate will be completed by the private physician. Also, dictate a short death summary, which should include a concise summary of the hospital course as well as the information included in the brief death note.

TOP TEN WORKUPS

15

CHEST PAIN

•
  Yes, it could be angina or MI. So,
assess the patient ASAP
. A thorough history and physical may elucidate a variety of possible diagnoses. However, it may lead to exactly the diagnosis that you thought of initially.

•
  Be sure to ask the nurse for vital signs. Initial verbal orders should include stat ECG, O
₂
to keep saturations >92%, sublingual nitroglycerin 0.4 mg, and aspirin 325 mg to the bedside. Confirm IV access.

Major Causes of Chest Pain

•
  Heart/vascular: angina, MI, acute pericarditis, aortic dissection

•
  Lungs: pneumonia, PE, pneumothorax

•
  GI: esophageal spasm, GERD, PUD, pancreatitis

•
  Other: costochondritis, herpes zoster, rib fracture, anxiety

Things You Don’t Want to Miss (Call Your Resident)

•
  MI

•
  Aortic dissection

•
  PE

•
  Pneumothorax

Key History

•
  Quickly review chart.

•
  Take a focused chest pain history including quality, duration, radiation, changes with respiration, diaphoresis, and N/V.

•
  Review ECG. If cardiac etiology is suspected, give NTG SL if SBP >90. Also, make the patient chew the aspirin, if not already given during the day.

Focused Examination

•
  General: Does the patient appear distressed or ill?

•
  Vitals: Hypotension is an ominous sign. Tachycardia may be from a PE or from pain. Bradycardia may be from AV block with inferior MI. Take BP in both arms to evaluate for aortic dissection. Fever may raise suspicion for PE.