SIU School of Medicine

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Division of General Internal Medicine

Intern Guidelines for Ward Medicine

Intern/Resident Duties

Admitting a patient:

Below is a list of duties and tasks that interns and residents must accomplish on the day of a patient’s admission. These duties must be carried out before the next day’s rounds.

1. A full H&P must be obtained from every patient on the day of admission. This includes a well documented neurological exam. An H&P must be dictated on the day of admission and this H&P should be copied to the attending physician for the wards, the patient’s primary care physician, and the resident who is dictating the H&P. Additionally, an abbreviated admission note should be written on the chart.

a. An accurate and complete medication list must be obtained from every patient on the day of admission. Include OTC agents. If the patient can not give you a full medication list, which includes the name of the drug, the dose of the drug and the frequency of administrations, then other sources must be sought out. These other sources can include the patient’s family, the patient’s pharmacy or pharmacies, the clinic where the patient sees their primary care physician, or old records. Because old records can be outdated, they should be your last source in terms of obtaining a complete and accurate medication list. Since many patients admitted to the hospital are suffering from one or more drug/drug interactions or drug side effects, it is of utmost importance that a complete drug list be obtained at the time of admission. This may necessitate calls to pharmacies or family members at late hours of the night, but this endeavor should be undertaken for the good of the patient.

b. As with medication lists, a full and accurate past medical history is very important from the outset of a patient’s care in a hospital. If the patient is not a reliable historian, old records (those on EMDAT being accessible from computers at any hour), the patient’s primary care provider, or family can be useful sources in a past medical history. In order to obtain information from the primary care physician of a patient, you may page that doctor directly, or call his/her office. For patients from out of town, the PCP may be the quickest way to get accurate past-medical history when admitted to the hospital. For all SIU-DGIM patients, the following procedure may be followed: Call the number listed for the nurse who takes care for the doctor in question. Talk to the nurse or leave a voice mail that includes the patient’s name and birth date so that the nurse can pull the patient’s chart. After the nurse obtains the chart, a process that usually takes two to three hours, you may go to the clinic to review the chart in person, or you may talk to the nurse over the phone to obtain pertinent information from the chart. Pertinent information that will be of use is a past medical history, a list of medications, the Power of Attorney for the patient, and any evidence of advance directives. Please have your fax number on hand so that information can be faxed to you for the nurse’s convenience. Be careful about relying solely on old records as they often have inaccurate information. Cross check whenever you can.

c. Please obtain the Power of Attorney for Healthcare on all patients. If the patient does not have a Power of Attorney for Healthcare, we need the phone number of the next of kin, or an emergency contact. Although the patient may seem as if they will not require the services of another to help with medical discussion making, things can change drastically. After the patient is no longer responsive this information can not be garnered from them.

d. Advance directives – Please obtain hard copies of any living wills, DNR statements or Power of Attorney papers that the patient has. Verbal statement of advance directives or the existence of a Power of Attorney may not be legally binding. Please document any of these conversations in the chart. The patient’s family or PCP is a good source for these documents.

e. Please call your attending about every patient that you see for admission or consultation. If you see a patient in the ER who does not appear to need hospitalization, please inform your attending of your suspicion. Not all patients deemed admissible by the ER physician truly need admission.

2. Initiating Patient Management
a. Stat medications/procedures/tests. If your patient needs a medication procedure or test immediately upon admission, please make sure all involved know that you are writing a stat order for a medication, lab or test. This includes the ward clerk, the nurse and other physicians involved in the patient’s care. Orders that are written without the stat designation run the risk of being done twenty-four hours or more after the patient is admitted. Please be aware that the hospital has a system of times of administration. What this means is that a medication that you write for b.i.d. at 10:00pm will not be given until 9:00am the next morning because the hospital’s b.i.d. timing system requires meds to be given at 9am and 9pm. If you intend for a medication to be given, a task or procedure to be done on the night of admission please make that clear in your order and make sure that everyone taking care of the patient understands that the order is urgent. Of particular use are “now and then orders” – i.e. give 25 mg of Atenolol now and then bid.

b. Protocol use – for CHF and pneumonia, as well as preoperative assessment, there are protocols to be used with specific order sets in admitting these patients. Ask the ward clerk for a copy of the appropriate protocol. The preoperative assessment can be found on the DGIM web page and printed out.

c. Review of primary data. Before rounds the next day, and preferably before calling your attending, it is important that you review in person all data in regard to your patient. This would include looking at gram stains, x-rays and EKG’s, as well as reviewing laboratory studies. It is not adequate to obtain the review of one of these tests by a radiology or lab tech. It is imperative that you yourself look at these tests in order to interpret them and discuss them with your attending.

d. NPO status. Consider whether your patient will receive a test or procedure in the near future that might require NPO status. If this is the case, make the patient NPO so that further testing and diagnosis will not be delayed the next morning. Don’t forget to evaluate the need for IV fluids or manipulation of the patient’s medical regimen secondary to the NPO status (Diabetic medications, for instance).

e. Please obtain the name of the patient’s primary care physician, the correct spelling of the physician’s name, the physician’s address and the physician’s phone number on the day of admission. Communication with the PCP is important in delivering good care to the patient.

f. Please notify the primary care physician of the patient’s admission on the night of admission. This may require paging the doctor or leaving a voice mail message. If the hour is late, you can leave an email (for SIU docs, it’s firstinitiallastname.siumed.edu) or call first thing in the morning. Always make it a priority to speak personally with the doctor. They may have important information for you.

g. Consider whether your patient will need physical therapy, occupational therapy, speech therapy, home heath or social work help during their admission. If so, ordering this as soon as possible after admission is important.

h. Consider whether your patient will be able to return home, or will need ECF (Extended Care Facility) after discharge. If placement in an ECF seems likely, please notify social work on the night of admission.

i. When writing orders, consider which daily labs should be ordered and be conservative.

j. Consider your patient’s diagnoses and write orders for daily weights, I’s & O’s, or orthostatics on the night of admission. Make sure that you write down the time of day when these tests will be done so that the data can be available for you on rounds. The nurses are busy, so only order things for which you have a use.

Consults

When asked to do an Internal Medicine Consult, please keep the following in mind:

1. Make sure it is a consult: the phrase “please notify internal medicine” may or may not be a consult. Clarify this with the primary service and ask them to write an order using the word “consult” (I know how this sounds, but it’s a legal issue) and specifying the issues to be addressed.

2. Make sure it is an SIU Internal Medicine consult. Ask the patient who their primary care physician is. If they have a doctor in Springfield, that doctor should probably be the person doing the consult. Clarify this with the consulting service. They may have been unaware that the patient has an available PCP, or that the patient belongs to Family Practice, etc.

2. Make sure you know what the consult is for, and focus on those issues. Though you need to completely assess the patient in order to understand the situation, your note should focus on the things for which the primary service asked for help.

3. If the consult is for pre-operative assessment, use the form our department has developed for that purpose. Open an internet browser on any computer connected to a printer, go to the www.siumed.edu website, and under the tab for Academics, click on Departments. Select General Internal Medicine. To the right of the screen there is a tab for the Pre-Operative Assessment Form. Click on this and print out the form that comes up. Fill out this form and place it on the chart in lieu of a written or dictated note.

4. Assess the patient, review the chart and review all pertinent data. If there are labs/x-rays to be reviewed, do so before writing the note so that the note reflects the endpoint of the consultative process instead of something midstream.

5. Provide a concise management plan. Stick to the issues about which we are consulted.

6. If you find something surprising or concerning, let the primary service know about it personally. Let them know about any stat labs, x rays or other consults you feel are necessary. The primary service is ultimately responsible for the patient, and should be part of any major decision making process.

7. Find out if we are a pure consultant or a co-manager. As co-managers, it’s assumed we will see the patient frequently and write orders as we see fit. If we are pure consultants, we will leave recommendations but not write orders, leaving final decisions up to the primary service. If you are functioning as a consultant, watch what you say to patients. If you tell a patient an x-ray will be done, and then the primary service decides not to do it, the patient will be confused. It’s best in these cases to explain to the patient that we’ll be discussing their care with their primary service and let the primary service talk to the patient about what will and won’t be done.


Daily Duties for Residents

Here is a list of things you should keep in mind while rounding on patients:

1. Vital signs and any change from previous.
2. Maximum temperature and current temperature.
3. I’s and O’s plus daily weights for patients in whom volume status is an issue (over 24 hours).
4. POC Blood Glucose Values (Accuchecks) and Diabetic medicine doses (especially insulin).
5. X-ray interpretations.
6. Gram stains
7. Lab results
8. Peripheral smears. (Examine these yourself. You do not need to request a special slide, unless you want a path review) You need to request that the slide be pulled about an hour before you go to pathology to review it.
9. Writing the note on the chart is your last priority
10. Date and TIME all notes and orders
11. Review the last twenty-four hours worth of notes in the chart
12. CBC’s must have the meanings of their differentials interpreted
13. Prioritize patients in case they can not all be seen on rounds
14. Order labs/tests in the morning if new problems occur. You do not have to wait until rounds if the need is urgent
15. Avoid portable x-rays
16. Read social work, therapy and nursing notes every morning prior to rounds
17. Every medication ordered needs an indication, a time and a date
18. Make sure to tell staff and nurses if you write a stat order and follow up on the stat order
19. Do not give up a procedure – always call your attending for supervision if your resident is unable.
20. Use generic drug names
21. Look at the MAR every day
22. Know the indication and mechanism of action for each drug your patient is on
23. Consider DVT prophylaxis on every patient
24. Review the need for Foley catheter, telemetry, IVFs and oxygen on a daily basis
25. Consider drug de-escalation on a daily basis (IV to PO, unused PRN’s, nebs to MDI)
26. Latin dosage abbreviations are no longer acceptable when writing orders. For instance, instead of Q.I.D., you must write “four times a day” or “every six hours” instead.

Sign Outs

With Work Hour Restrictions, we all do a lot more cross coverage on patients than in the past. Studies show that patients get worse care and have worse outcomes when taken care of by a cross coverage intern, so we must take special care to transfer useful information to the people taking care of our patients when we’re off.

For the person signing out patients:

1. Always sign out to the on call intern in person. You may have to wait until they have a moment to concentrate on the task. The best time to sign out patients is after noon conference. The designated time and place for sign out is 1 pm at the room designated for noon conference. The post call intern must sign out their patients at this time.

2. If you are not ready to sign out your patients immediately after noon conference, or if there is no noon conference (weekends, etc), page the on call intern to sign out when you are ready. Out of courtesy, you should go to wherever the on call intern is to give them a face to face sign out.

3. When you sign out a patient, hand over your card for that patient. Possession of the card represents responsibility for the patient. Please make sure that you have filled out the card with durable information. Utilize the to-do list on the back of the card to list items to be done in your absence.

4. Keep your beeper on and with you at all times. The on call intern, in extreme circumstances, may need to call you.

5. Be specific. If you are asking for diuresis, suggest doses. If you are monitoring the H and H, advise when to transfuse. If something worked / has not worked in the past, indicate it. Don’t make the cross cover re-invent the wheel.

6. Try not to be in denial. You may be hoping your patient doesn’t once again get agitated at night, but if it happened the last three nights, face it – it’s probably going to happen again. Talk it over with your attending and write an order that covers the situation. The cross cover intern may still need to see the patient, but at least there will be a plan in place.

7. Page the intern on call in the morning to get your cards back and hear about what happened in the night. Talk about problems on rounds and think about how you can reduce the chances of something being a problem on the next night. Orders for sleeping pills are an example – this should never be a cross coverage issue more than once.

For the on call intern who is accepting sign outs:

The phrase “It’s not my patient . . .” does not exist in your vocabulary. If you’ve got the card, it’s your patient.

1. Ask questions. Sign out should not be passive. If an issue is unclear, ask for clarification. Get as much context from the intern taking care of the patient as possible.

2. Make sure there is a plan. If an event is likely to occur (“watch for agitation”), ask for a plan (if x happens, do y).

3. Consider making a time sheet for your on call night where you mark in reminders of things you are supposed to check on. Don’t rely on nurses to call with lab values or vitals.

4. All problems are easier to solve if you attend to them in person. This is a golden rule of cross coverage. See the patient if at all possible, and especially if:

• A change has taken place
• Any one of the vital signs is not normal (ask for the vitals – sometimes they have not been checked and are abnormal)
• The nurse seems uncertain or confused
• An order is called for

Remember that you can quickly learn a lot by dropping by to see what’s going on in person. It’s much more efficient than having a phone conversation in that it allays the anxiety of you, the nurse and the patient. You’ll ultimately get fewer calls from the nurses if you show them you are taking their concerns seriously. Please keep in mind that a nurse who calls and then is unable to clearly tell you what the problem is should not be dismissed. That nurse is trying to convey the message that something is concerning them about the patient. This is a patient you need to see in person.

5. Write a note if you have seen the patient. This can be very short.

6. Unless you are writing for antibiotics, don’t write continuous orders. Write one time or x 24 hour orders. Continuance should be up to the primary team.

7. Call someone if a major change has taken place – especially if you are upgrading level of care. Also call if you are making a major clinical decision (antibiotics, pressors, stat CT’s, DNR).

8. Who should you call? Call your senior if you’re at all unsure of what to do. If there is a major piece of information needed and it’s not in the chart but you think the usual residents in charge of the patients would know it, page them. Always feel free to call the attendings and definitely call them with major issues.

9. Interns will page you in the morning to get the cards back and hear about what happened in the night. If something significant happened, write it on the card (add it to the problem list or put it on the back).
1 Discharging a patient

Below is a list of duties and tasks that interns and residents must accomplish on the day of a patient’s discharge:

1. For proper discharge, you must tell everyone involved with the patient about the discharge ahead of time. This includes the patient, the patient’s family, the nursing staff, social work, any cross cover interns or residents, and home health/home infusion. You must directly contact the patient’s PCP to let them know what happened in the hospital and what follow up issues exist. The cross cover interns/resident needs to know about any impending discharges in case changes in the patient’s status make a difference in regard to the way that the patients will be discharged.

2. Prescriptions:

A. Call the pharmacy and cancel old prescriptions.
B. Write out or call in new prescriptions.
C. During the patient’s hospitalization have all the patient’s prescriptions brought in and personally call and cancel the prescriptions or throw out the medications that the patient is no longer on.
D. Discuss with the patient what sort of budget is realistic in regards to their medications. Make sure the medication that you prescribe is one that they can afford and one that is essential to their health.
E. Home Health – especially in regard to devices that the patient needs at home and particular services that the patient needs to file for.
F. Home Infusion – please have the doses of medications decided upon before you call Home Infusion.
G. Never write a prescription for more than thirty days (never write for refills).
H. Review any OTC meds the patient takes. See if any should be avoided.


3. Transport:

The patient may be able to enlist their family to move them. Otherwise, ambulance or van rides may be needed. Social work can help you arrange this, but it takes time and can not be done at a moment’s notice. They should know that transportation will be needed at least one day ahead of time. Try to have an idea of what time in the day the patient will be discharged and not just the day.

4. Clinic Appointments:

Consider whether the patient will need PCP appointments, appointments with individual clinics, such as the clinic at Capital Community Health Care, SIU clinics, or specialist appointments. It is your duty to arrange these appointments for the patient.
SIU Receptionists 545-3880
Capital Community Health Care 544-1101
Anticoagulation Clinic 545-9298


5. Informing PCP:

Call the PCP with the report on the patient’s discharge and obtain a fax number so that we can fax the discharge summary to the primary care physician.

6. Dictate the discharge summary:

This can be done one day prior to discharge and marked stat so that it is available when the patient is ready to go home. Last minute changes can be added as an amendment on the day of discharge. Send a copy to you, the PCP and your ward attending.


7. Written list of instructions:

The patient needs a written list of instructions, their medications, who to call in case of problems and appointments before they leave. Make sure the patient knows where the clinics for their appointments are located. If they are going to an ECF (including St. John’s North), the facility needs to know who the primary care physician will be at the nursing home. Please note that this will never be the hospitalist. In addition ECF needs a written indication (a diagnosis or symptom) for each drug prescribed to the patient.

Patient Tracking Cards

These cards, with a color corresponding to your team, are used to transfer data. It is essential that you fill out one card on every admission or consult to your service, and turn it in when the patient is discharged. The cards are used in the following ways:

1. The Card represents your patient. When you sign out the patient, turn over the card to the on-call intern. Use the back of the card to list things for the on call intern to do for your patient. In the morning when you return to work, page the on call intern to get your cards back.

2. The Card ensures that people will know what happened to your patient. When patients are discharged, they often have questions and call their PCP’s office. Your card will serve as a reference even before discharge summaries are available to the office staff.

3. You only get credit for seeing a patient if you fill out a card. Interns are required to see a certain number of patients on the general wards, and the only way you get credit for an admission is by turning in a card.


You must fill out and turn in a card on every patient you see on the wards – admissions, transfers, consults, even the dread psych H and P.

All interns and intern equivalents need to keep a set of cards – rotators from other departments and MS4’s doing subinternships are included.

Pick up new cards and turn in cards at morning report.

The cards are color coded:

Yellow Team A
Pink Team B
Blue Team C
Green Team D

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