Intern Ward Indoctrination

1. Intern WardIndoctrination

2. ACGME’s Core Competencies • Patient care • Medical knowledge • Interpersonal & communication skills • Professionalism • Practice-based learning • Systems-based practice www.acgme.org

3. Hierarchy of Values • Patient care • Adherence to work hour rules • Formal education • Conferences & lectures • Bedside teaching • Individual study

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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

10. Work Hours: RulesNO 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.

11. 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 H&P’s must be done • ALL patients must be added to sign out • ALL Narrative Summaries must be started • ALL notes for the following day can be started / outlined

12. 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

13. Caring for Patients—Have some type of method to track patient vitals/meds/labs on daily basis– see examples: Name: Allergies: PROBLEM LIST:INPT MEDS / Start: 1. SSN: 2. 3. PCM: 4. DVT Px: 5. CIWA/Banana Bag: 6. Stool Softener:Age: HPI: PMHx: OUTPT MEDS:

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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.

21. Discharge Summary • Likely the most important document during hospitalization • ALL medications must be clearly listed • Must have follow-up scheduled with PCM

22. 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!

23. SIGN OUT – see intern handbook

24. 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?

25. 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?

26. 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…”

27. 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

28. Questions or Concerns • Call YOUR Resident • Call YOUR Resident • Call YOUR Resident

29. Internal Medicine Homepage http://nmcsdintranet.med.navy.mil