7.29.09 Haag Intern DC Summary

7/29/2019 7.29.09 Haag Intern DC Summary

1/13

Jason Haag

Intern Conference


2/13

Plan ahead

Use Resident Assistants to

Make follow up appointments

On WebCis f/u lists

Fax discharge summaries/patient information


3/13

Plan ahead Talk to your patient

How do they pay for meds?

Who is going to pick them out?

How long will the hospital stay be?

Who do they live with at home?

Do they have home health/home PT already in place?


4/13

Start your discharge summary

Can put in procedures

Secondary diagnosis

Follow up appointments Pertinent labs

Start the hospital course


5/13

Brief Discharge Summary

Most important take home message to patients

Diagnosis

what you have/had done Medications

***reconciled with home list***

Discharge instructions

What to do/what to look out for

Follow up appointments

Does not have to be exact date


6/13

Talk with Social Worker

Be very nice to these people

About

Ride They can provide one (ambulance, taxi, bus)

Medications

They can help pay for them (pharm assistance)

Home Health/Home PT They can arrange it


7/13

Talk with the Nurses

Keep them in the loop

Nurses will provide

Patient education How do I administer lovenox, do accuchecks?

They will decipher your discharge summary intopatient talk

Make sure they understand whats going on with thepatient


8/13

Talk with Home Infusion

Talk early and often

They provide home IV therapy Can arrange IV therapy on Saturday

Can arrange acute changes in antibiotic choice

IFthey know about the patient ahead of time


9/13

Communicate with PCP

Dont have to call

Send phone message with dx/tx

Not a novel (they can read your d/c summary), justgive them a heads up


10/13

TALK WITH THE PATIENT!!!!!!!!!

They will have questions that they want their doctorto answer

The more time you put in early in the day answeringquestions will save you later


11/13

Key Points

Carry over all diagnosis

Reconcile medication list

Procedures/imaging No need to list every CXR, KUB

Pertinent Labs

Admission Chem-10, CBC

Special labs


12/13

Hospital Course

List by problems

Overview of hospitalization

Not on HD#1then on HD#2 Express the maximum amount of information in the

minimum amount of space

Be clear, concise, and coherent

The longer it is, the less likely someone is to read it


13/13

Must do Brief Discharge Summary

To dictate or not to dictate

+/- of dictation

If you start falling behind They will find you

Medical Records keeps a log of physician of record andwill track you down for delinquent d/c summaries

If you are too delinquent they wont let you work (i.e. wontpay you) till your caught up

Documents

7.29.09 Haag Intern DC Summary