intern survival guide ward 2

8/3/2019 Intern Survival Guide Ward 2

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InternIntern

SurvivalSurvival

Guide:Guide:

Ward/Night Float EditionWard

/Night Float Edition


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OutlineOutline

IntroductionIntroduction SchedulesSchedules Prep workPrep work Division of laborDivision of labor Where things areWhere things are When things happenWhen things happen AM Sign-OutAM Sign-Out

Work RoundsWork Rounds

Morning ReportMorning Report Attending RoundsAttending Rounds Private PMDsPrivate PMDs

OrdersOrders AdmissionsAdmissions Progress notesProgress notes DischargesDischarges Running theRunning the

List/UpdatingList/Updating MedicalMedical

Students/TeachingStudents/Teaching PM Sign-OutPM Sign-Out Weekends andWeekends and

HolidaysHolidays Night FloatNight Float

Misc tips, tricks andMisc tips, tricks and


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So youre starting theSo youre starting the

floorfloorThe pediatric ward is located on 11N,The pediatric ward is located on 11N,

to the left of the elevators.to the left of the elevators.The resident call room is the firstThe resident call room is the first

room to the left as you walk throughroom to the left as you walk throughthe double doors onto the floor.the double doors onto the floor.Please ask one of the seniors or thePlease ask one of the seniors or the

chiefs for the code.chiefs for the code. Dress codeDress code is business attire is business attire white coat. If youre on call on awhite coat. If youre on call on aFriday night, you can change intoFriday night, you can change into

scrubs before sign-out. If youre onscrubs before sign-out. If youre on


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Floor InternFloor Intern

For 3 months, you belong to the 11N floor teamFor 3 months, you belong to the 11N floor team

as their intern. The rotations are labor intensiveas their intern. The rotations are labor intensive

(and very intimidating at first!) but can be very(and very intimidating at first!) but can be very

rewarding.rewarding.

The floor team will consist of medical students, 4-5The floor team will consist of medical students, 4-5

interns (usually 3 or 4 pediatric interns + 1 familyinterns (usually 3 or 4 pediatric interns + 1 family

medicine intern) and 2 seniors.medicine intern) and 2 seniors.

Patients will be split as evenly as possible, butPatients will be split as evenly as possible, but

expect to carry at least 4-5 per day on average.expect to carry at least 4-5 per day on average.During the busier months, this number can easilyDuring the busier months, this number can easily

double.double. Time managementTime management will likely be thewill likely be the

most important thing you learn your intern year.most important thing you learn your intern year.

Remember you play an active role in yourRemember you play an active role in your


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SchedulingScheduling

During each month of floor rotation, your workDuring each month of floor rotation, your workhours are officially 7am (AM signout) 6pm (PMhours are officially 7am (AM signout) 6pm (PMsignout).signout).

For every four weeks that youre on the floor, youllFor every four weeks that youre on the floor, youll

work a 24-hour Friday, a 24-hour Saturday and awork a 24-hour Friday, a 24-hour Saturday and aSunday (7am-7pm)Sunday (7am-7pm)

Be prepared to push the 80-hour work week limits.Be prepared to push the 80-hour work week limits.Sleep when you can, eat when you can, and dontSleep when you can, eat when you can, and dontforget to keep yourself hydrated.forget to keep yourself hydrated.


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Schedule AccessSchedule Access

To access your personal schedule, go to:To access your personal schedule, go to: New Innovations: https://rms1.newinnov.com/LoginNew Innovations: https://rms1.newinnov.com/Login After logging in, hitAfter logging in, hit

View:View:

Take a couple of hours one day and justTake a couple of hours one day and justbrowse through new innovations. It doesbrowse through new innovations. It does

take some getting used to.take some getting used to.
https://rms1.newinnov.com/Login/Login.aspxhttps://rms1.newinnov.com/Login/Login.aspxhttps://rms1.newinnov.com/Login/Login.aspx


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PreparationPreparation

Before you start the floor, familiarizeBefore you start the floor, familiarizeyourself with where everything is. Duringyourself with where everything is. Duringorientation week, take the time to reallyorientation week, take the time to reallybe nosy and look around at everything.be nosy and look around at everything.

Get a sturdy binder or clipboard, black andGet a sturdy binder or clipboard, black andcolored pens and a small calculatorcolored pens and a small calculator(Staples has cute keychain calculators for(Staples has cute keychain calculators for$1.)$1.)

The day before you start, one of the otherThe day before you start, one of the otherinterns will sign out their patients to you.interns will sign out their patients to you.Make sure that you know everything aboutMake sure that you know everything abouteach one of those patients: take noteseach one of those patients: take notesduring the verbal sign-out, comb the chartduring the verbal sign-out, comb the chart

for pertinent information (H&P and off-for pertinent information (H&P and off-


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Flow SheetsFlow Sheets Flow sheets are found eitherFlow sheets are found either

in the big cabinet on 11N or @in the big cabinet on 11N or @pedsportal. fellinahole.compedsportal. fellinahole.comunder chart data.under chart data.

They exist to have allThey exist to have all

pertinent information, pastpertinent information, pastand present, at fingertips andand present, at fingertips andfacilitate good signout.facilitate good signout.

Most interns like to use themMost interns like to use themand you should receive oneand you should receive onefor each patient you arefor each patient you aresigned out, but there are nosigned out, but there are noguarantees. A good rule is toguarantees. A good rule is tomake a new one for eachmake a new one for eachpatient youre signed out, aspatient youre signed out, aswell as new patients yourewell as new patients youre

assigned.assigned. You should hand them off toYou should hand them off to


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Where Things Are:Where Things Are:

ChartsCharts Red ChartsRed Charts are usually found next to the clerk. Inare usually found next to the clerk. In

them youll find:them youll find: Patient stickersPatient stickers Completed H&P with growth chartCompleted H&P with growth chart

Progress notesProgress notes Completed consultsCompleted consults ED and outside recordsED and outside records

Blue ChartsBlue Charts are found bedside. They house onlyare found bedside. They house onlyasthma scores.asthma scores.

Powerchart:Powerchart: our electronic medical recordour electronic medical record OrdersOrders Meds/MARMeds/MAR All vitals (including height, weight and HC) and I/Os.All vitals (including height, weight and HC) and I/Os.

All patient results including radiology (PACS) and oldAll patient results including radiology (PACS) and oldrecords (Eclipsys)records (Eclipsys)


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Where Things Are:Where Things Are:

MiscellaneousMiscellaneous Forms/PaperworkForms/Paperwork::

The big gray cabinet in the core houses most ofThe big gray cabinet in the core houses most of

the blank forms youll ever need, includingthe blank forms youll ever need, including

blank H&Ps, flow sheets and dischargeblank H&Ps, flow sheets and dischargepaperwork.paperwork.

If you need paperwork not found in the grayIf you need paperwork not found in the gray

cabinet for any reason, ask a clerk or yourcabinet for any reason, ask a clerk or your

senior.senior.

Other Items in the CoreOther Items in the Core:: Big bulletin boardBig bulletin board

Frequently called phone numbersFrequently called phone numbers

Frequently written orders/fluidsFrequently written orders/fluids


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Frequently CalledFrequently Called

NumbersNumbersFloors11N 4-115211N core 4-1169, 4-814811S/PICU 4-110011S/HemeOnc 4-110111N call room 4-388411N conference room 4-2419

NICU 4-2001Nursery 4-2110Peds ED 8-3500OR 4-2444Admitting 4-2591

ClinicsClinics (appt) 444-KIDS

Tech Park 4-0651, 4-4601Patchogue 4-6319, 4-6314Islip 581-9330East Moriches 878-8050

PharmaciesPediatric 8-2420

Adult 4-2680TPN 4-1440

LabsBlood bank 4-2626Chemistry 4-2365Cytogenetics 4-2749Cytology 4-2216Hematology 4-2375Histology 4-2236Immunology 4-2231

Microbiology 4-2370Phlebotomy 4-7626Virology 4-2374PFT 4-1765EEG 4-2260EKG 4-1760, 4-5481Echo 4-1770, 4-3769

Operator: Dial 04-

60004-

7788

RadiologyCT 42408, 4-3715CT ER 4-9002; 4-8150MRI 4-2515Neuroradiology 4-1443Peds Radiology 4-7227Radiology JR 4-7450Radiology SR 4-7451

Radiology Supervisor 4-7453Reading room 4-2882, 4-9514Ultrasound 4-7455X-ray 4-5056X-ray tech 4-7453

Other ServicesChild Life 4-3840Dietary 4-1440Dietician 4-1436PT 4-2620OT 42533

Transport 4-2980Medical records 4-1300Social work 4-2552Infection control 4-2239Child psych 4-1250Patient relations 4-2880

Faxes11N 4-1355PICU 4-8983CT 4-6237MRI 4-8959

Tech Park 4-4990Patchogue 4-6327Islip 581-9561

East Moriches 878-8084

Misc.Elaine 4-2020Computer help 4-HELPNB screen (LIC 211855)

518-474-1753800-535-3079

Poison control516-542-2323800-222-1222

SB Pharmacy 751-4477American Red Cross(CPR)

924-6700


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When Things HappenWhen Things Happen

DailyDailyPrior to 7am: Preround7am 8am: AM sign-out and work rounds

8am 9am: Morning Report (except Wednesdays, GrandRounds)

9am attending rounds:Work

Midmorning: Attending Rounds

Midmorning - 6pm: Work

6pm: PM sign-out

Throughout the day: Update your senior!

WeeklyWeeklyTuesdays at 2pm Chatting with Chandran

Thursdays at 10am Chairwomans Rounds

Weekly at 10:30am Subspecialty Rounds

Weekly Intern Symposium


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Pre-RoundingPre-Rounding

When youre ward intern, what time you arrive at theWhen youre ward intern, what time you arrive at thehospital is usually dependent on how many patientshospital is usually dependent on how many patientsyou carry. Plan on being there at approximately 6am.you carry. Plan on being there at approximately 6am.

Find the night intern and nurses to get sign-out onFind the night intern and nurses to get sign-out onovernight events.overnight events.

Obtain vitals (including ranges if abnormal), ins andObtain vitals (including ranges if abnormal), ins andouts, asthma scores, new labs, etc. Look at radiologyouts, asthma scores, new labs, etc. Look at radiologystudies done overnight (dont just read the report).studies done overnight (dont just read the report).

See all of your respiratory kids and as many otherSee all of your respiratory kids and as many otherpatients you can before AM sign-out. Patients withpatients you can before AM sign-out. Patients withacute issues should have priority. If the patient isacute issues should have priority. If the patient issleeping, you do not have to wake him/her for a fullsleeping, you do not have to wake him/her for a fullphysical, but when pertinent, do a focused exam.physical, but when pertinent, do a focused exam.

TipTip: Organize yourself while pre-rounding in order to: Organize yourself while pre-rounding in order toprepare for work rounds. Either on your flow sheet orprepare for work rounds. Either on your flow sheet oryour own sheet, write a one-sentence summary aboutyour own sheet, write a one-sentence summary about

each patient, vitals and labs youve collected andeach patient, vitals and labs youve collected andcurrent medications. Start a checklist for what youcurrent medications. Start a checklist for what you


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Pre-Rounding: PersonalPre-Rounding: Personal

Flow Sheet ExampleFlow Sheet Example


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AM Sign-OutAM Sign-Out

AM sign-out begins promptly at 7am in theAM sign-out begins promptly at 7am in the

11N conference room across from the call11N conference room across from the call

room. Itsroom. Its extremely importantextremely importantto be onto be on

time for every scheduled event, includingtime for every scheduled event, includingthis one.this one.

Assigning patientsAssigning patients: As the night intern: As the night intern

presents new admissions (morepresents new admissions (more

information on this later), the seniors willinformation on this later), the seniors willassign them to interns based on currentassign them to interns based on current

patient numbers. Take note of anypatient numbers. Take note of any

service/staff patient youre assigned, asservice/staff patient youre assigned, as

those re uire a little more work.those require a little more work.


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Work RoundsWork Rounds

The entire team (including night intern and senior)The entire team (including night intern and senior)

round in the conference room in the morning as anround in the conference room in the morning as an

introduction for the day.introduction for the day.

Presentations should be short, with a briefPresentations should be short, with a brief

introduction to the patient, any overnight events,introduction to the patient, any overnight events,

ROS by system, pertinent physical exam findings ifROS by system, pertinent physical exam findings if

you examined the patient, pertinent vitals,you examined the patient, pertinent vitals,

assessment and plan for the day.assessment and plan for the day.

TipTip: When presenting vitals, include asthma: When presenting vitals, include asthmascores, ranges (if pertinent) and UOP in cc/kg/dayscores, ranges (if pertinent) and UOP in cc/kg/day

(this is especially important in our nephrology(this is especially important in our nephrology

patients).patients).

OnOn WednesdaysWednesdays, work rounds are conducted one, work rounds are conducted one


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Senior Sign-OutSenior Sign-Out

TipTip: Try to structure your presentations for work: Try to structure your presentations for workrounds by systems as laid by the seniors sign-outrounds by systems as laid by the seniors sign-out

sheet.sheet. Patient BC is a 10-month-old male with rotavirus +Patient BC is a 10-month-old male with rotavirus +AGE, hospital day 2. No overnight events. Patient is onAGE, hospital day 2. No overnight events. Patient is ona regular diet and maintenance fluids. Tolerating POa regular diet and maintenance fluids. Tolerating POwell, no vomiting. No respiratory or cardiovascularwell, no vomiting. No respiratory or cardiovascularissues. Vitals are [here, including the weight andissues. Vitals are [here, including the weight and

change], with a UOP of 2cc/kg/hr. Had 3 episodes ofchange], with a UOP of 2cc/kg/hr. Had 3 episodes ofdiarrhea overnight, which is improved over yesterday.diarrhea overnight, which is improved over yesterday.Plan is f/u stool studies, heplock his IV today, monitorPlan is f/u stool studies, heplock his IV today, monitorIs/Os, discuss with Dr. Baram possible d/c.Is/Os, discuss with Dr. Baram possible d/c.

Be prepared to move fast the team has to round onBe prepared to move fast the team has to round onthe entire floor before morning report.the entire floor before morning report.

If rounding is not complete by 8am, rounds concludeIf rounding is not complete by 8am, rounds conclude


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Morning ReportMorning Report

TheThe goalgoal of morning report is to provide an interactiveof morning report is to provide an interactiveforum for house staff to develop skills in presentation,forum for house staff to develop skills in presentation,diagnostic evaluation and patient treatment.diagnostic evaluation and patient treatment.

It is run by the chief resident with multiple faculty, includingIt is run by the chief resident with multiple faculty, includingDr. McGovern, present.Dr. McGovern, present.

Cases are usually selected by the chiefs with input from theCases are usually selected by the chiefs with input from thecurrent seniors. Seniors should share their knowledge withcurrent seniors. Seniors should share their knowledge withthe interns and the interns should feel free to ask questionsthe interns and the interns should feel free to ask questionsand offer responses.and offer responses.

As a new intern, you will not be expected to present. InAs a new intern, you will not be expected to present. Inyour last six months of internship, however, the baton willyour last six months of internship, however, the baton willfall to you. Therefore, you should pay attention to yourfall to you. Therefore, you should pay attention to your

seniors how they prepare, present and respond toseniors how they prepare, present and respond tocriticism.criticism.

In general, presentations should include the chiefIn general, presentations should include the chiefcomplaint, acomplaint, a chronologicchronologic HPI (what happened at home,HPI (what happened at home,then at the outside hospital, then at our ED), past history,then at the outside hospital, then at our ED), past history,chronologic physical exam (did yours look different from thechronologic physical exam (did yours look different from the

outside hospital?), any and all labs/diagnostic done.outside hospital?), any and all labs/diagnostic done. Comprehensive treatment of entire topic is not necessaryComprehensive treatment of entire topic is not necessary


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Morning Report: RunningMorning Report: Running

the Listthe List Before cases are presented, the chiefs willBefore cases are presented, the chiefs will

run the list of patients who have new and/orrun the list of patients who have new and/orinteresting radiographs.interesting radiographs.

After cases are presented, the chiefs willAfter cases are presented, the chiefs will

prompt the interns to run the entire list.prompt the interns to run the entire list. For either of these situations, be prepared toFor either of these situations, be prepared to

give a one-liner about your patients: Patientgive a one-liner about your patients: PatientJJ is a 7-year-old male admitted with a leftJJ is a 7-year-old male admitted with a leftsurpacondylar fracture after falling from asurpacondylar fracture after falling from a

trampoline, now s/p CRPP. (trampoline, now s/p CRPP. (TipTip always alwaysinclude mechanism of injury).include mechanism of injury). OnOn MondaysMondays, we run, we run allalladmissions fromadmissions from

Friday through Sunday. If you are on over theFriday through Sunday. If you are on over theweekend, keep a list handy (usually taped toweekend, keep a list handy (usually taped to

the cabinet above the senior computer) ofthe cabinet above the senior computer) of--


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Attending RoundsAttending Rounds

After morning report, you should get all time-sensitive workAfter morning report, you should get all time-sensitive work

done: discharges (should be done before 11am if possible),done: discharges (should be done before 11am if possible),

calling consults, seeing newly admitted patients (withcalling consults, seeing newly admitted patients (with

service patients getting priority) and reading their chartsservice patients getting priority) and reading their charts

thoroughly, and seeing all service patients.thoroughly, and seeing all service patients.

Attending rounds are bedside and family-centered withAttending rounds are bedside and family-centered with

presentations either outside of the patients room or insidepresentations either outside of the patients room or inside

with family present.with family present. If the patient is established, your presentation will be the sameIf the patient is established, your presentation will be the same

as work rounds, except your emphasis will be on physical exam,as work rounds, except your emphasis will be on physical exam,

assessment and plan.assessment and plan. If the patient is a new patient, you will have to present theIf the patient is a new patient, you will have to present the

entire H&P.entire H&P. Tip Tip Because the hospitalist will physically takeBecause the hospitalist will physically takethe H&P from a newly admitted patients chart to write on, youthe H&P from a newly admitted patients chart to write on, you

should either photocopy it or take good notes from it beforeshould either photocopy it or take good notes from it before

rounding.rounding. You should defer all presentations to your medical studentsYou should defer all presentations to your medical students


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Private PMDsPrivate PMDs

Some community pediatricians have admittingSome community pediatricians have admittingprivileges. If a patient is admitted under a privateprivileges. If a patient is admitted under a privatePMD service, that PMD is their attending.PMD service, that PMD is their attending.

The physician on-call to the hospital will usuallyThe physician on-call to the hospital will usuallyround in the morning (usually at exactly the timeround in the morning (usually at exactly the timeof work rounds). They will drop by the conferenceof work rounds). They will drop by the conferenceroom to pull out the night intern/senior in order toroom to pull out the night intern/senior in order toimpart the plan for the day.impart the plan for the day.

Because there are no formal attending rounds withBecause there are no formal attending rounds withprivate PMDs, you should have a low threshold forprivate PMDs, you should have a low threshold for

calling them during the day when any situationcalling them during the day when any situationarises.arises.

For a list of PMDs and their contact information,For a list of PMDs and their contact information,check out fellinahole atcheck out fellinahole athttp://fellinahole.com/peds/pmd.html.http://fellinahole.com/peds/pmd.html.

TipTip: Most will appreciate being updated at least: Most will appreciate being updated at leasttwice durin the da once in late mornin and


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OrdersOrders

All order writing is now done electronically throughAll order writing is now done electronically throughour CPOE system. Please refer to your PowerChartour CPOE system. Please refer to your PowerCharttraining for more specific instructions.training for more specific instructions.

You should notify the patients nurse of any newYou should notify the patients nurse of any new

orders, especially if the order is written as STAT.orders, especially if the order is written as STAT. Lexi-Comp online (http://online.lexi.com/crlonline) isLexi-Comp online (http://online.lexi.com/crlonline) is

our hospital approved reference for medication.our hospital approved reference for medication. Since CPOE has eliminated order rewrites, it isSince CPOE has eliminated order rewrites, it is

prudent and necessary to check every order everyprudent and necessary to check every order everyday to make sure that you havent hit a soft stop orday to make sure that you havent hit a soft stop orfallen off of the MAR.fallen off of the MAR.

Compare active orders to what the patient shouldCompare active orders to what the patient shouldbe getting to exactly what the patient is gettingbe getting to exactly what the patient is getting

(MAR) every day.(MAR) every day.


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More OrdersMore Orders

Orders that need to be renewed dailyOrders that need to be renewed daily::

Restraints, 1:1 orders.Restraints, 1:1 orders.

Orders for phlebotomy need to be put in for theOrders for phlebotomy need to be put in for the

exact times of 6:00am and 11:00am (when theexact times of 6:00am and 11:00am (when the

phlebotomy team rounds). These orders shouldphlebotomy team rounds). These orders should

ideally be put in the night before, but if that is notideally be put in the night before, but if that is not

possible, make sure to give the phlebotomistspossible, make sure to give the phlebotomists

enough time to see your order.enough time to see your order.

If you are too late for phlebotomy or would ratherIf you are too late for phlebotomy or would ratherhave the nurses collect blood for you, put in thehave the nurses collect blood for you, put in the

order as a nurse collect and tell that patientsorder as a nurse collect and tell that patients

nurse.nurse.

Our nurses are very professional and will place IVs,Our nurses are very professional and will place IVs,


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RadiologyRadiology

After putting in orders for desired study,After putting in orders for desired study,call the appropriate department in order tocall the appropriate department in order tomake sure they are aware. Try (and itmake sure they are aware. Try (and itmay be difficult) to get an estimated timemay be difficult) to get an estimated time

that the study will be done.that the study will be done. If contrast is to be given, obtain parentalIf contrast is to be given, obtain parental

consent and place it in the chart.consent and place it in the chart. You should discuss with your senior residentYou should discuss with your senior resident

whether the patient should be NPO for thewhether the patient should be NPO for thestudy, but in general:study, but in general: Patients who need studies under anesthesia andPatients who need studies under anesthesia and

patients who need CTs with contrast will need to bepatients who need CTs with contrast will need to beNPO for a certain amount of time before the studyNPO for a certain amount of time before the study(usually 4-6 hours).(usually 4-6 hours).

MRIs usually do not require a patient to be NPO.MRIs usually do not require a patient to be NPO. If a patient requires anesthesia, call theIf a patient requires anesthesia, call the


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Prescription WritingPrescription Writing

Use the hospital DEA number (AU9053125) andUse the hospital DEA number (AU9053125) andyour personal suffix at the top of the script.your personal suffix at the top of the script.Always stamp at the top.Always stamp at the top.

Medicaid patients require an attending licenseMedicaid patients require an attending license

number to be written at the top. License numbersnumber to be written at the top. License numberscan be found here:can be found here:http://www.health.state.ny.us/professionals/doctors/cohttp://www.health.state.ny.us/professionals/doctors/co

Prescriptions do not need to contain any math butPrescriptions do not need to contain any math butthey do need to specify what the concentration isthey do need to specify what the concentration is

of any suspension or tab/pill you write for:of any suspension or tab/pill you write for:

Amoxicillin 400mg/5ml suspensionAmoxicillin 400mg/5ml suspension

Sig: 6mL PO BID for 10 daysSig: 6mL PO BID for 10 days

Disp: QSDisp: QS
http://www.health.state.ny.us/professionals/doctors/conduct/http://www.health.state.ny.us/professionals/doctors/conduct/http://www.health.state.ny.us/professionals/doctors/conduct/


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ConsultsConsults

When arranging for a consult, page the resident orWhen arranging for a consult, page the resident orfellow covering for that service. If there are nofellow covering for that service. If there are noresidents or fellows, page the attending directly.residents or fellows, page the attending directly. Exception #1Exception #1: If there are no ophthalmology residents: If there are no ophthalmology residents

seeing pediatrics patients, consults are attending-to-seeing pediatrics patients, consults are attending-to-

attending.attending. Exception #2Exception #2: ENT consults are: ENT consults are alwaysalways attending-to-attending-to-

attending.attending. Exception #3Exception #3: Cardiology and child pysch consults are: Cardiology and child pysch consults are

arranged via their main offices. To consult either one ofarranged via their main offices. To consult either one ofthese services, have the operator connect you to theirthese services, have the operator connect you to their

main office.main office. TipTip: Before calling a cardiology consult, you should: Before calling a cardiology consult, you shouldobtain an EKG and 4-limb blood pressure. They are alwaysobtain an EKG and 4-limb blood pressure. They are alwayshelpful!helpful!

Fill out the top part of the consult form and leave itFill out the top part of the consult form and leave itin the chart.in the chart.

Never call a consult without attending approval.Never call a consult without attending approval.


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AdmissionsAdmissions

Patients who are admitted during the dayPatients who are admitted during the dayto a general pediatric service (service,to a general pediatric service (service,private PMD, non-surgical subspecialties)private PMD, non-surgical subspecialties)will require:will require:

A complete history and physical, after which anA complete history and physical, after which anH&P packetH&P packet needs to be completed.needs to be completed. Growth chart and BMIGrowth chart and BMI Admission ordersAdmission orders PMD notificationPMD notification

PMDs need to be notified of admission both whenPMDs need to be notified of admission both whenthey are the attending and when they are not.they are the attending and when they are not.

Any private pediatrician of a service patient orAny private pediatrician of a service patient orpatient from another service (ie surgery, ortho)patient from another service (ie surgery, ortho)should be notified of admission.should be notified of admission.

Medication Reconciliation (if not done byMedication Reconciliation (if not done bynurses)nurses)


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Admissions: OtherAdmissions: Other

ServicesServices Surgical servicesSurgical services

We co-follow pediatric surgery, orthopedic,We co-follow pediatric surgery, orthopedic,OMFS (etc) patients. When they are admitted, aOMFS (etc) patients. When they are admitted, afull H&P is not required only an accept/post-opfull H&P is not required only an accept/post-op

note is required.note is required. Daily SOAP notes are also required.Daily SOAP notes are also required. Patient issues or questions about plan of carePatient issues or questions about plan of care

should be discussed with the primary team.should be discussed with the primary team.

Orders should not be written on their patients withoutOrders should not be written on their patients withouttheir approval, but you should check to make suretheir approval, but you should check to make surethey are correct.they are correct.

The reverse is also true: surgical teams should notThe reverse is also true: surgical teams should notbe writing orders on service or private patients thatbe writing orders on service or private patients thatthey may be consulting on. Please contact yourthey may be consulting on. Please contact your

senior or chief if this happens.senior or chief if this happens.


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Admissions: OtherAdmissions: Other

ServicesServices NeurosurgeryNeurosurgery

Same as surgical services. The only difference isSame as surgical services. The only difference is

that the pediatric neurosurgery service oftenthat the pediatric neurosurgery service often

requires a pediatric consult.requires a pediatric consult.

TipTip Write your Write youraccept/post-op note on theaccept/post-op note on the

consult forms.consult forms.

Any questions should be directed toward your seniorAny questions should be directed toward your senior

or Nancy Strong, the pediatric neurosurgery NP.or Nancy Strong, the pediatric neurosurgery NP.

ENTENT ENT patients are often admitted under theENT patients are often admitted under the

hospitalist service. Therefore, theyhospitalist service. Therefore, they dodo require anrequire an

H&P packet, daily SOAP notes and orders (thoughH&P packet, daily SOAP notes and orders (though

they should not be written without ENT attendingthey should not be written without ENT attendinga roval .a roval .


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Admissions: The H&PAdmissions: The H&P

You are responsible for doing admissions with theYou are responsible for doing admissions with thesenior resident and medical student (if you aresenior resident and medical student (if you areassigned to one.)assigned to one.)

At that time, you will ask the questions regardingAt that time, you will ask the questions regardingthe history. (After your medical student hasthe history. (After your medical student has

watched you do this once or twice, you shouldwatched you do this once or twice, you shouldpass the baton to him or her.)pass the baton to him or her.)

You will all complete the physical together.You will all complete the physical together. TipTip Dont forget the oto-ophthalmoscope to Dont forget the oto-ophthalmoscope to

examine the ears and the pharynx. Check to see if thereexamine the ears and the pharynx. Check to see if there

are pediatric otoscopic specula (the smaller ones) andare pediatric otoscopic specula (the smaller ones) andtongue depressors with the scope before you go in.tongue depressors with the scope before you go in. Your H&P format will be laid out for you in ourYour H&P format will be laid out for you in our

easy-to-use pre-printed intern packet.easy-to-use pre-printed intern packet. TipTip Sticker every page, back and front. Sticker every page, back and front. TipTip Until you get comfortable writing a Until you get comfortable writing a

chronological, sensible HPI, take notes on the back ofchronological, sensible HPI, take notes on the back of


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Progress (SOAP) NotesProgress (SOAP) Notes

There should be a progress note in the chart for each patientThere should be a progress note in the chart for each patientevery day.every day. ExceptionException: If the H&P of a new patient admitted: If the H&P of a new patient admitted

overnight is dated after midnight, a SOAP note is notovernight is dated after midnight, a SOAP note is notrequired.required.

In the first line of the note, remind the reader why theIn the first line of the note, remind the reader why thepatient was admitted: 7-year-old with reactive airwaypatient was admitted: 7-year-old with reactive airwaydisease exacerbation and hypoxia.disease exacerbation and hypoxia.

The SOAP format:The SOAP format: S (subjective):S (subjective): How the patient did overnight, anyHow the patient did overnight, any

events, any complaints.events, any complaints.

O (objective):O (objective): Physical exam including ALL vitalsPhysical exam including ALL vitals(weight, I/Os), labs, radiology.(weight, I/Os), labs, radiology. A (assessment):A (assessment): Summary of status.Summary of status. P (plan):P (plan): Goals by systemsGoals by systems

TipTip It helps to arrange your systems by the order It helps to arrange your systems by the orderthey are laid out on the senior signout sheet. (FEN,they are laid out on the senior signout sheet. (FEN,

Resp, Cardio, ID)Resp, Cardio, ID) Date, time, stamp and sign every page of your progressDate, time, stamp and sign every page of your progress


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DischargesDischarges

To discharge a patient, you must complete a dischargeTo discharge a patient, you must complete a dischargesummary (found in the gray cabinet in the core), writesummary (found in the gray cabinet in the core), writenecessary prescriptions, and arrange follow-up withnecessary prescriptions, and arrange follow-up withPMD.PMD.

Contact all consulting services at point of discharge andContact all consulting services at point of discharge andask if they would like follow-up if not addressed in theirask if they would like follow-up if not addressed in theirnote.note.

In theory, the discharge paperwork should be started asIn theory, the discharge paperwork should be started assoon as the patient is admitted so that completion doessoon as the patient is admitted so that completion doesnot delay discharge.not delay discharge. Keep incomplete summaries in the top left desk drawer inKeep incomplete summaries in the top left desk drawer in

the core.the core. Make sure there is enough information on each summary soMake sure there is enough information on each summary so

that a resident covering you over the weekend or while youthat a resident covering you over the weekend or while youare at clinic is able to discharge the patient successfully.are at clinic is able to discharge the patient successfully.

Make sure to write your name under responsible dictatingMake sure to write your name under responsible dictatingresident.resident.


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DischargesDischarges

If a patient is going home on an unusualIf a patient is going home on an unusualmedication, call the outside pharmacy andmedication, call the outside pharmacy andmake sure they will have it available in a timelymake sure they will have it available in a timelymanner.manner.

If the pharmacy is closed or will not have theIf the pharmacy is closed or will not have themedicine in an acceptable period of time, see ifmedicine in an acceptable period of time, see ifthere is a spare dose in the patients drawer tothere is a spare dose in the patients drawer toget them through the day and/or the nextget them through the day and/or the nextmorning. The pharmacy supervisor is alsomorning. The pharmacy supervisor is alsosympathetic to the realities of these situationssympathetic to the realities of these situations

and will sometimes agree to send up an extraand will sometimes agree to send up an extradose or two before discharge.dose or two before discharge.

Magical pharmacies that seem to have veryMagical pharmacies that seem to have veryunusual medications are Stony Brook Pharmacyunusual medications are Stony Brook Pharmacy(no affiliation) and Fairview Pharmacy.(no affiliation) and Fairview Pharmacy.


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DictationsDictations

All patients admitted for more than 48 hours willAll patients admitted for more than 48 hours willrequire a dictation.require a dictation.

TipTip Try to dictate patients in a timely fashion, Try to dictate patients in a timely fashion,optimally before the charts leave the floor. Afteroptimally before the charts leave the floor. Afterthat, you must head up to the 13that, you must head up to the 13thth floor to medicalfloor to medical

records and have your charts pulled for you torecords and have your charts pulled for you todictate.dictate.

The rules:The rules:You may have no more thanYou may have no more than twentytwenty on your liston your list

until January 1until January 1stst(then no more than(then no more than tenten

thereafter).thereafter).You may not haveYou may not have anyany chart older than 30 days onchart older than 30 days on

your deficient list.your deficient list. If any of these rules are broken, medical records willIf any of these rules are broken, medical records will

contact Elaine and put a letter in your mailboxcontact Elaine and put a letter in your mailboxthreatening suspension of medical privileges, finesthreatening suspension of medical privileges, fines

and other bad things. In addition, the chiefs may beand other bad things. In addition, the chiefs may beforced to give you anforced to give you an extra call.extra call.


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DictationsDictations


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TransfersTransfers

Accepting a TransferAccepting a Transfer Usually from the PICUUsually from the PICU Read through chart thoroughly, including the otherRead through chart thoroughly, including the other

services transfer note.services transfer note.

Talk to the patient, get history, do physical.Talk to the patient, get history, do physical. Double-check already written orders.Double-check already written orders. Write an accept note. Make sure to include the hospitalWrite an accept note. Make sure to include the hospital

course until the time the patient is transferred to yourcourse until the time the patient is transferred to yourservice.service.

Transferring to Another ServiceTransferring to Another Service Usually to the PICUUsually to the PICU You MUST write a transfer note, which is SOAP noteYou MUST write a transfer note, which is SOAP note

format with more detail. Include a brief HPI and hospitalformat with more detail. Include a brief HPI and hospitalcourse until time of transfer.course until time of transfer.

Write transfer orders in PowerChartWrite transfer orders in PowerChart econcile meds usin the trans er o tion.


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Off Service NotesOff Service Notes

Off-service notesOff-service notesshould be writtenshould be writtenforforcomplicated/chroncomplicated/chronic patients, as wellic patients, as well

as patients whoas patients whohave been on thehave been on thefloor for morefloor for morethan 3-4 days withthan 3-4 days withno dischargeno dischargeplans.plans.

The off-serviceThe off-servicenote is a morenote is a morecomprehensivecomprehensiveSOAP note,SOAP note,including problemincluding problemlist, brief HPI andlist, brief HPI and

hospital coursehospital course


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Running the List/UpdatesRunning the List/Updates

During the course of the day, update yourDuring the course of the day, update yoursenior (and your patients/families)senior (and your patients/families)frequently.frequently. TipTip Parents should not be asking the night Parents should not be asking the night

team about long-term plans! If they are, that isteam about long-term plans! If they are, that isa clue that you should be more on top ofa clue that you should be more on top ofupdating your families.updating your families.

At 5pm, you should be prepared to giveAt 5pm, you should be prepared to give

your senior final updates for the day. Thisyour senior final updates for the day. Thisisis keykeyto leaving the hospital on time.to leaving the hospital on time.

Before evening sign-out at 6PM, youBefore evening sign-out at 6PM, youshould have obtained the most recentshould have obtained the most recent

vitals for your patients and have a goodvitals for your patients and have a good

di l d


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Medical Students &Medical Students &

TeachingTeaching Medical students will be assigned to you whenMedical students will be assigned to you when

they come on service. Typically, they will follow 2-they come on service. Typically, they will follow 2-4 of your patients during the course of the week,4 of your patients during the course of the week,after which they will follow a different intern and aafter which they will follow a different intern and a

different student will follow you.different student will follow you. Med students should be seeing patients andMed students should be seeing patients andwriting notes. They should also be presentingwriting notes. They should also be presentingduring work rounds and attending rounds.during work rounds and attending rounds.

Be sure to take time to teach, even if its onlyBe sure to take time to teach, even if its only

pearls here and there, or tips and tricks forpearls here and there, or tips and tricks forinternship.internship.

Constructive criticism is especially important inConstructive criticism is especially important inhistory taking, physical exam skills and notehistory taking, physical exam skills and notewriting. Before co-signing medical student notes,writing. Before co-signing medical student notes,they should be reviewed and discussed.they should be reviewed and discussed.


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PM Sign-OutPM Sign-Out

Evening sign-out begins at 6PM in the 11NEvening sign-out begins at 6PM in the 11Nconference room.conference room.

Presentations to the night team should be brief,Presentations to the night team should be brief,but they should also include any and all pertinentbut they should also include any and all pertinent

information about your patients that would beinformation about your patients that would beimportant to know overnight.important to know overnight. Report by systems, including your updated vitals.Report by systems, including your updated vitals. Briefly list important medications.Briefly list important medications.

Finish with a summary of night issues/things toFinish with a summary of night issues/things tolook out for or accomplish overnight, as well aslook out for or accomplish overnight, as well aslabwork expected in the AM if there is a value thatlabwork expected in the AM if there is a value thatneeds to be watched for.needs to be watched for.

If necessary, also sign out if anyone needs to beIf necessary, also sign out if anyone needs to be

called for a specific parameter (ie, calling the endocalled for a specific parameter (ie, calling the endo--


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Night FloatNight Float

The night intern rotation consists of two two-weekThe night intern rotation consists of two two-weekblocks of nights in which you will work Sundayblocks of nights in which you will work Sundaythrough Thursday, 6pm through 8am.through Thursday, 6pm through 8am.

Your day will start withYour day will start with PM sign-outPM sign-out. Make sure. Make sure

to listen carefully about anything pendingto listen carefully about anything pendingovernight, taking notes on the sign-out sheets ifovernight, taking notes on the sign-out sheets ifnecessary. Both the floor team and heme/onc willnecessary. Both the floor team and heme/onc willsign out to you, so it can seem like a lot. Feel freesign out to you, so it can seem like a lot. Feel freeto ask for clarification if something is unclear.to ask for clarification if something is unclear.

Depending on the night senior and number ofDepending on the night senior and number ofpending admissions, many night teams will dopending admissions, many night teams will donight rounds,night rounds, which consist mainly of introducingwhich consist mainly of introducingyourself to the patients and families and asking ifyourself to the patients and families and asking ifthey have any problems or concerns.they have any problems or concerns.

For the rest of the night, your job isFor the rest of the night, your job is admissionsadmissions..


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Night Float: AdmissionsNight Float: Admissions

Whenever your senior gets paged for an admission,Whenever your senior gets paged for an admission,ask him or her to tell you about the patient, too. Itsask him or her to tell you about the patient, too. Itsnice to know whats coming.nice to know whats coming.

When a patient first comes up, grab the chart.When a patient first comes up, grab the chart.Thumb through all of the records already there,Thumb through all of the records already there,

such as outside hospital or ED records. You shouldsuch as outside hospital or ED records. You shouldhave your HPI in chronologic order, and thathave your HPI in chronologic order, and thatincludes what was done for them before they got toincludes what was done for them before they got tothe floor.the floor.

You will needYou will need a lota lot of stickers.of stickers.

All PMDs need to be notified of admission, even ifAll PMDs need to be notified of admission, even ifits 3am.its 3am. Private attendings need to be spoken with in order toPrivate attendings need to be spoken with in order to

solidify plans for their patients.solidify plans for their patients. Pediatricians of service patients and surgical patientsPediatricians of service patients and surgical patients

need to be notified but not necessarily spoken to. Talk toneed to be notified but not necessarily spoken to. Talk totheir service and leave a message for the morning. This istheir service and leave a message for the morning. This is


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Night Float: OvernightNight Float: Overnight

Check vitals and labs frequently. If somethingCheck vitals and labs frequently. If somethinglooks suspicious or impossible (respiratory rate oflooks suspicious or impossible (respiratory rate of0, for example), get clarification! Make sure to0, for example), get clarification! Make sure tohave the nurses or CAs repeat any abnormalhave the nurses or CAs repeat any abnormallooking vital signs.looking vital signs.

If you are called to the bedside for whateverIf you are called to the bedside for whateverreason, write a 2-3 linereason, write a 2-3 line event noteevent note in the chartin the chartstating why you were called, what you did, andstating why you were called, what you did, andwhat the resolution of the event was.what the resolution of the event was.

Eat (deli opens at 12), sleep (seriously) and go toEat (deli opens at 12), sleep (seriously) and go to

the bathroom when you can.the bathroom when you can. Before signing out in the morning, get the vitalsBefore signing out in the morning, get the vitals

and labs on all of your new admissions, listen toand labs on all of your new admissions, listen toyour respiratory kids and put all your paperworkyour respiratory kids and put all your paperworktogether.together.

Interns will start showing up around 6am. UpdateInterns will start showing up around 6am. Updatethem on what ha ened to their atients


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Night Float: AM Sign-Out &Night Float: AM Sign-Out &

BeyondBeyond AM sign-out begins with the night internAM sign-out begins with the night intern

presenting new patients. Presentations shouldpresenting new patients. Presentations shouldconsist ofconsist of A brief HPI including what was done for them, ifA brief HPI including what was done for them, if

anything, at outside hospitals, the ED, and on the flooranything, at outside hospitals, the ED, and on the floor

PMH pertinent to HPIPMH pertinent to HPI Significant labs/radiographsSignificant labs/radiographs Pertinent physical exam findingsPertinent physical exam findings Brief assessment/plan.Brief assessment/plan.

It will take awhile to finesse, but theseIt will take awhile to finesse, but these

presentations shouldpresentations should onlyonlybe 2-3 minutes long.be 2-3 minutes long. It is always good practice to ask for feedback from yourIt is always good practice to ask for feedback from yourseniors about how your presentations are going andseniors about how your presentations are going andwhat you can do to improve.what you can do to improve.

After sign-out, the night team joins the day teamAfter sign-out, the night team joins the day teamon work rounds. Monday through Thursdayon work rounds. Monday through Thursday

intern survival guide ward 2

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