Medicine Sub I Primer

5/22/2018 Medicine Sub I Primer

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Primer to the Internal Medicine Subinternship

A Guide Produced by the Clerkship Directors in InternalMedicine

EDITOR:

Heather E Harrell! MD

"ni#ersity o$ %lorida Colle&e o$ Medicine

A''OCIATE EDITOR':Meenakshy ( Aiyer! MD

"ni#ersity o$ IllinoisColle&e o$ Medicine at Peoria

)oel * Appel! DO+ayne 'tate "ni#ersity 'chool o$ Medicine

Gurpreet Dhali,al! MD

"ni#ersity o$ Cali$ornia! 'an %rancisco'chool o$ Medicine

Peter Gliatto! MDMount 'inai 'chool o$ Medicine

Michelle ',eet! MD

Rush Medical Colle&eo$ Rush "ni#ersity


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Table of Contents

INTRODUCTION.........................................................................................................................4

SECTION 1: MAKING THE MOST OF YOUR SUINTERNSHI!....................................."

SECTION #: $ORKING IN HEA%TH CARE TEAMS.........................................................&

C'a(te) 1* Cons+ltat,ons............................................................................................................-

C'a(te) #* Effet,/e Use of an Inte)()ete)................................................................................11

C'a(te) 0* Anse),n2 a N+)se !a2e.........................................................................................10

C'a(te) 4* T,(s fo) T),a2,n2 C)oss*Co/e)...............................................................................1"

SECTION 0: AD3ANCED COMMUNICATION SKI%%S...................................................1&

C'a(te) "* Ne2ot,at,n2 Confl,t................................................................................................1-

C'a(te) &* Del,/e),n2 a Nes...............................................................................................#5

C'a(te) -* D,s+ss,n2 A/e)se E/ents ,t' !at,ents..............................................................##

C'a(te) 6* De,s,onal Ca(a,t7 an Info)8e Consent.........................................................#0

C'a(te) 9* Obta,n,n2 A/ane D,)et,/es an Do+8ent,n2 DNR....................................#&

SECTION 4: TRANSITIONS OF CARE................................................................................05

C'a(te) 15* C)oss Co/e)a2e.....................................................................................................01

C'a(te) 11* T)ansfe) an Off*Se)/,e Notes..........................................................................0&

C'a(te) 1#* D,s'a)2e !lann,n2 Co+nsel,n2 an S+88a)7...............................................06

SECTION ": !RACTICA% NUTS AND O%TS...................................................................4"

C'a(te) 10* Essent,al T,8e Mana2e8ent an O)2an,;at,onal S


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C'a(te) 1"* A Do;en !ea)ls to Kee( Yo+) !at,ents Safe......................................................."1

C'a(te) 1&* $'at to Do $'en a !at,ent D,es........................................................................."#

C'a(te) 1-* T,(s fo) D,tat,n2.................................................................................................."4

C'a(te) 16* Do+8ent,n2 !)oe+)es....................................................................................."&

,bl,o2)a('7..............................................................................................................................."-

3


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INTRODUCTION

Welcome to your internal medicine subinternship. We are delighted that you have joined us for

this short period when you will have your first taste of what internship will be like and willexperience more of what internal medicine has to offer. Regardless of your future career path,

we wish you the most stimulating, rewarding, and transforming experience possible over thecoming weeks.

he information in this booklet has been produced through the collaboration and consensus of

internal medicine subinternship directors across the country, most of whom have spent many

years teaching, evaluating, and advising students. !t should help fill in some common gaps in theformal medical curriculum as you begin your internship. " complimentary resource for your

subinternship is the CDIM Internal Medicine Subinternship Curriculum and CDIM Internal

Medicine Subinternship Training Problems, which cover more traditional medical topicscommonly encountered during the internal medicine subinternship. !t is available free of charge

online at#

www.im.org$Resources$%ducation$&tudents$'earning$()!*subinternship(urriculum$+ages$default.aspx

+lease note information provided by your subinternship director should take precedence over

these suggestions.

Disclaimer Any reference to a product in this book does not imply any endorsement of theproduct by CDIM or the editor and authors. Product references are only included to provideexamples of resources and are not meant to be exhaustive lists of available material.
http://www.im.org/toolbox/curriculum/Students/Learning/CDIMsubinternshipCurriculum/Pages/default.aspxhttp://www.im.org/toolbox/curriculum/Students/Learning/CDIMsubinternshipCurriculum/Pages/default.aspxhttp://www.im.org/toolbox/curriculum/Students/Learning/CDIMsubinternshipCurriculum/Pages/default.aspxhttp://www.im.org/toolbox/curriculum/Students/Learning/CDIMsubinternshipCurriculum/Pages/default.aspx


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SECTION 1: MAKING THE MOST OF YOUR SUBINTERNSHIP

It is a darin and transformin experience to attempt to heal anotherperson.! Edmund Pellegrino, MD

-or many of you, the subinternship will be your first real taste of autonomous patient care.

"lthough you will of course be supervised, you are expected to be the first person evaluatingyour patients and generating assessments and action plans. ou will be an integral part of the

team, working directly with nurses, therapists, consultants, and other health care providers.

+atients/ post0hospital care will be determined largely by how well you anticipate and facilitatetheir discharge needs. ou will also be actively involved in the kinds of difficult discussions you

may have only observed up to this point. With these increased responsibilities, efficiency will

now be of paramount importance to your success. ou will feel the potentially competingpressures of patient care, proper documentation, early discharges, and conferences. he tips and

resources in this guide were developed to prepare you for many of the practical, day0to0day

issues you will face when caring for hospitali1ed patients. hey are intended to direct you tostrategies that improve both the efficiency and uality of patient care.


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SECTION 2: ORKING IN HEA!TH CARE TEAMS

4iven the diversity of backgrounds and complexity of patients in the 25st century, medicine has

become a team sport and no one appreciates that more than a busy intern. -acilitating

communication among the increasingly large health care team is a critical skill that will help you

care for your patients. " new intern uickly learns that one of the best resources is the nurse. !fyou have not yet asked a nurse, 6What do we usually do in this situation78 chances are you will.

%ven with nursing shortages and increased nurse to patient ratios, the nurses still have thegreatest opportunity to pick up subtle changes in your patients while also ensuring that the orders

are carried out.

(onsultants also play a key role in the care of most patients, whether it is the physical therapist

helping the patient walk or the transplant nephrologist managing a complex cocktail of

immunosuppressants. (onveying complex data to patients and their families in a way that they

understand while encouraging their participation in decisions about care is an essential duty for aphysician. his section will provide strategies to maximi1e your communication with both the

health care team and the patient.

9


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CHAPTER 1: CONSU!TATIONS". #obert $u% MDIndiana &niversity 'chool of Medicine

+hysicians commonly reuest consultations to#

4et expert advice on diagnosis.

4et expert advice on management.

4et assistance in scheduling or performing a procedure or test.

"rrange follow0up.

!f you and your team already understand what is going on with a patient and are able to provide

the care with your attending, there is little use in calling for a consult. :efore calling, consider

how the consultant may change your management. !f a consultant would add to the case, then

make sure you are very clear on what it is you and your team are asking the consultant to dobefore calling. 6(urbsiding,8 or asking consultants for an opinion without formally seeing the

patient, may seem convenient but is discouraged.

HO TO MA"IMI#E YOUR CONSU!T

!e)fo)8 t'e ,n,t,al o)< +( an 'a/e test )es+lts )ea7

-or most stable patients, obtain and wait for the results of relevant diagnostic tests beforecontacting the consultant. -or example, a stable female patient with a chief complaint of

abdominal pain will typically have a urinalysis, serum amylase$lipase, and serum or urine

pregnancy test performed;these test results should be available prior to contacting the

consultant.

-or unstable patients or those with suspected unstable conditions ;e.g., bleeding varices,dissecting aortic aneurysm, etc.


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+rior to reuesting a consult, be sure that you have discussed your plans with your supervising

resident or attending so that she can#

"pprove these plans.

%nsure that all pertinent data are available.

>elp coach you on what to say, including the level of urgency of the consult.

&ome faculty and upper level fellows do not think it is appropriate for students to call

consultations. !f you experience this attitude, do not take it personally. &imply apologi1e andhave your resident call.

)evelop the capacity to handle disagreements professionally and to compromise appropriately.;&ee (hapter on negotiating conflict.< !n the academic setting, the person reuesting a consult

is commonly the least experienced caregiver on the primary team ;e.g., medical students or

interns


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4ive)ele/ant l,n,al ,nfo)8at,on;in standard &A"+ format to help you and your listener

follow a systematic framework, only what that particular consultant needs to know< ?????? who was admittedfrom the %) yesterday after he presented with ?????? ;chief complaint and abbreviated

>+!< and was found to have ??????, ??????, etc. on physical exam and ??????, ??????,etc. on labs$radiology$%(4.8

4ive your l,n,al ,8()ess,onand brief hospital course.

o 6:ased on his presentation, our working diagnosis is ??????.8

o 6his is what we/ve done for him thus far# ??????.8

&tate the +)2en7 of the clinical situation to let your consultants know if this is a patient they

need to see now or a patient who can wait until later in the day or even until the followingday to be evaluated. :e prepared to give additional details to back up your clinical

impression, particularly in urgent situations.

o 6his man is still actively bleeding and his systolic :+ has remained in the CDs despite

aggressive volume resuscitation. We/d appreciate it if you would see him now.8

o 6Eolume status, serum potassium, and acid0base status are all stable. &he has no clinical

evidence of uremia at this time, and she is not oliguric or anuric. herefore, this consultcan likely wait until later today or even tomorrow.8

(onsider )e*,te)at,n2 7o+) >+est,on;or reason< for the consult if the steps above have taken

longer or necessitated a more involved conversation.

o 6&o again, we would like you to evaluate this patient for ?????? so that you can give us

some advice on ??????.8

>ave the patient/s medical record number and location ready to provide and make sure you

obtain the name of the attending physician who will staff the consult. ;" written reuest for

consultation that includes the names and specialties of the attending physicians reuesting

and performing the consult along with the uestion or reason for the consultation may be

reuired for reimbursement and possibly other logistical reasons.+,)e t'e ()esene of an

e?(e),ene ('7s,,an. >owever, you are encouraged to play an active role in these

conversations, even taking the lead with supervision.

his section will highlight some of the most freuent challenges to communication that arise in

the inpatient setting and provide practical and proven strategies to prepare you to negotiate them

successfully.

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CHAPTER ): NEGOTIATING CONF!ICT

urpreet Dhali)al% MD&niversity of California% 'an *rancisco% 'chool of Medicine

he subinternship marks a transition where your success, both as a student and as a clinician, is

measured by getting things done for your patients. he key to getting things done is to workeffectively with people in the hospital. >owever, when such a diverse group of people areworking together ;residents, fellows, faculty, nurses, family members, social workers, etc.ave the patient tell you his or her understanding of what you have said.

I !ant to ma0e sure you understand !hat !e have tal0ed about) Can you tell me yourunderstanding of !hat !e have discussed#

"void overwhelming the patient with details. %xpect that the patient will remember very

little information beyond the bad news itself. "nticipate subseuent visits where more

detailed information can be discussed.

Res(on,n2 to t'e !at,entBs Feel,n2s

'isten carefullyJ identify and acknowledge the patient/s and family/s emotional reactions.

*ake sure your body language conveys compassion and openness to uestions 7leaning

for!ard* having tissue available* using discretion about touching the patient to givecomfort4some !elcome this and others shrin0 from it8.

"ssess for thoughts of self0harm. Could you tell me a little bit about ho! you are

feeling#

!lann,n2 an Follo*T')o+2'

&ummari1e your meeting and make specific follow0up plans. I !ill return in the

morning) It is normal to thin0 of 3uestions as soon as I leave the room) 9ust !rite them

do!n as they come to mind so !e can tal0 about them in the morning) *ake sure this

plan meets the patient/s needs.

Follo*U( 3,s,ts "sk the patient if he understands what has been discussed about his condition, and repeat

or correct information as necessary.

!nuire about the patient/s emotional and spiritual needs and what support systems he or

she has in place.

Gse interdisciplinary services to enhance patient care.

(onclude each visit with a summary and follow0up plan of care.

(onveying bad news is a process, not an event. !t is expected that this experience may deeplyaffect you. Remember also to address your own personal feelings and needs following the

delivery of bad news. *ake sure you have an outlet to process these emotions whether it isspeaking with a friend, journaling, or even allowing yourself some uiet time alone. "rranging a

debriefing session with your resident or attending for feedback is also an opportunity to discuss

your reaction to the experience.

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CHAPTER +: DISCUSSING AD&ERSE E&ENTS ITH PATIENTS

'usan allaher%MD'tate &niversity of /e) 0ork at 1u2alo'chool of Medicine 3 1iomedical 'ciences

he !nstitute of *edicine defines an 6adverse event8 as an injury caused by medicalmanagement rather than the patient/s underlying disease. "dverse events are common, estimated

to affect 5DH of all patients. )egrees of severity include serious;causing death, permanent

injury or transient but potentially life0threatening harmowever, as a subintern, your role in discussing adverse events with patients is not well

defined.

!f you think you witness an adverse event in a patient/s care, avoid independently revealing thisinformation to the patient. Rather, assume the role of intermediary and relate the patient/s

concerns ;or your own< about possible adverse events to the attending and ask to be present for

the discussion between the attending and patient. his discussion may include a detailedexplanation of events, the need for an investigation to more accurately define the causes of the

event, and sharing the results of an investigation. !n cases where an adverse event occurred, the

attending should issue an apology to acknowledge and accept responsibility for the event. heattending may need the assistance of patient safety or risk management officials as these

disclosure discussions may be emotionally charged or have legal conseuences.

&adly, some physicians are still very threatened by acknowledging and reporting adverse eventsto the point they may mislead or even lie to the patient and expect you to go along. his

situation is never acceptable. 'ying to or deceiving a patient is always wrong. !f it happens,

report it to your subinternship director or hospital/s risk management officer.

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CHAPTER ,: DECISIONA! CAPACITY AND INFORMED CONSENT

Monica Ann 'ha)% MD&niversity of ,ouisville 'chool of Medicine

"s a subintern, you will play an important role in helping patients understand their conditions

and care options available to them. &ometimes, this role will involve obtaining informedconsent. !nformed consent is the process by which a patient understands her condition andavailable treatments and participates in choices about her health care. he physician has an

obligation to make recommendations for care in accordance with good medical practice and to

present medical information accurately to the patient in language that she can understand. -or

the patient/s consent to be valid, the patient must have the capacity to make medical decisionsand the consent must be voluntary.

he legal standard of informed consent varies from state to state and it is your responsibility tolearn reuirements specific to your state. >owever, all informed consent should include a

discussion of the#

+atient/s diagnosis.

Kature and purpose of the proposed procedure or intervention.

Risks and benefits of the proposed procedure or treatment.

"vailable and reasonable alternative procedures or treatments, including doing nothing.

Risks and benefits of the alternative procedures or treatments.

"ssessment of patient understanding.

"cceptance or a declining of the intervention by the patient.

)iscussing these elements with the patient provides the physician useful information to help

assess a patient/s decisional capacity and to ensure informed consent occurs.

)ecisional capacity and informed consent are contextual and decision0specific. herefore, a

patient may have the capacity to refuse a routine blood draw but not necessarily a life0saving

surgery. )ecisional capacity is also different from competence, which is a legal definition.%stablishing decisional or decision0making capacity should include assessment of#

Gnderstanding ;the ability to comprehend what you explain


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"dditionally, the patient/s decision should be consistent with what the physician knows of the

patient and her value system. -or example, a patient may refuse a therapy for which she can listthe risks, benefits, and alternatives, but if reason for the refusal is irrational or inconsistent with

stated values, the patient/s decisional capacity should be doubted. !n the event a patient cannot

demonstrate decisional capacity, you and your supervising physicians should seek out a surrogatedecision maker.

he following is a specific example of how to approach the process of informed consent in astep0by0step fashion.

E?(la,n t'e (at,entBs ,a2nos,s +s,n2 s,8(le lan2+a2e. We are !orried that the s!elling in

your belly is e,tra fluid* called ascites) This fluid can collect for many different reasons*including liver or heart problems) To give you the best diagnosis and treatment* I am

recommending a procedure called a paracentesis)

E?(la,n t'e ()o(ose ()oe+)e. 1 paracentesis is the medical term !e use for removing somefluid from your belly) We have to sample this fluid and send it to the lab so !e can try to

determine the cause and best treatment to prevent it from coming bac0 or getting infected) :irst*!e clean your s0in off !ith special soap to decrease the ris0 of infection) 1lthough !e do use a

needle to dra! out the fluid* !e numb the area of s0in first so it !ont hurt any more than a shot)

1fter !e remove the fluid* !e ta0e the needle out and put a band/aid over the area) We should

be able to have results on the fluid in the same day as the procedure or the ne,t day so that !ecan hopefully tell you more about !hy your belly is full of fluid)

E?(la,n t'e ),s


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asking the patient if she understands does not give you adeuate information to determine true

understanding.

Re,te)ate t'e (at,entBs onsent to t'e ,nte)/ent,on. It seems that you understand the ris0s and

benefits of having the paracentesis and that you !ant to proceed !ith the procedure) Do you

have any other 3uestions# I !ill document in your medical record our discussion and youragreement to proceed !ith the paracentesis)

+hysicians may proceed with treatment in emergency situations ;without obtaining informedconsent< if all threeof the following criteria are met#

he situation is a life threatening emergency and time is of the essence.

he patient does not have decisional capacity and no legal surrogate decision maker is

available.

" reasonable person would consent to the emergency treatment.

Remember that a patient with decisional capacity may decline any and all treatments and the

patient can withdraw consent at any time.

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CHAPTER -: OBTAINING AD&ANCED DIRECTI&ES AND DOCUMENTING

DNR

Peter liatto% MDMount 'inai 'chool of Medicine

Michelle ')eet% MD#ush Medical Collee of #ush &niversity

+atients in the hospital often have complex, multi0system, and life0threatening conditions. "s a

subintern, one of your responsibilities is to understand your patients/ values and preferences asthey relate to health care decisions. o care for and advocate for your patients, it is essential that

you clarify what outcomes they anticipate and what they hope for from their care. "dvanced

directives are a patient/s way to specify the type of care he would like ;or not like< to receive

should he lose the ability to make medical decisions for himself. "dvanced directives, includingcode status, should be established early in a patient/s hospitali1ation. "dditionally, it is just as

important to know who the patient would want as his health care proxy ;or surrogate


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proxy must be able and willing to make decisions that reflect the patient/s wishes. he physician

should not be the health care proxy. " health care proxy form can be filled out in the hospital

and does not reuire a lawyer. !f a patient lacks capacity to make a decision about a health careproxy and has not already appointed one, the patient/s next0of0kin should function as the

patient/s health care agent and there is a legal hierarchy to determine which next of kin serves

this role ;spouse, child, parent, then sibling is a typical order


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facing the !orst case scenario* and !e are doing everything !e can right no! to aim for the best

case scenario) What are your thoughts about these possibilities#

D,s+ss,n2 a DNR O)e) S(e,f,all7

Kow that you have established joint understanding ofthe patient/s present and future, you should

discuss resuscitation. +ause often to assess reactions, allow uestions, and clarify areas ofconfusion. %stablish the context in which treatment or resuscitation could be considered. ou

may want to offer youropinion that a )KR order may be indicated.

I agree that it ma0es sense to treat this infection !ith antibiotics and use dialysis at least

temporarily to help get you through this illness) What I need to clarify !ith you are your !ishes

should your condition deteriorate) What I mean is' should the infection cause too much stress

on your heart and cause it to stop beating* you !ould die) The only option !e have at that pointis cardiopulmonary resuscitation* or CP2* !hich is pushing on the heart to 0eep it beating*

shoc0ing the heart if necessary* and trying strong drugs to ma0e the heart beat again) Most

patients !ith your health conditions !ill also need to be placed on a breathing machine in this

situation) We can attempt all of these life support measures if that is your !ish) The otheroption is to continue all of the treatments !e are currently doing 7antibiotics and dialysis8 but if

they !ere not !or0ing and your heart did stop !e !ould not move to these life support measuresand !e !ould instead allo! you to die naturally)

Kote how this example clarifies that (+R is a treatmentthat attempts to reverse death, while also

making it clear thata decision about )KR status is not necessarily related to decisionsabout the

intensity of the effort to cure or treat the underlying conditions.

"nother approach to this discussion is to offer your recommendation first. ou can offer your

suggestion, just as you would for other medical therapies and decisions. "fter all, (+R is a

medical

therapy with indications and contraindications. ou should also emphasi1e that )KRstatus does not mean that the medical team will not treat the patient any longer.

Res(on to E8ot,ons

+atients, families, and surrogates often develop a significant emotional response to a discussion

of resuscitation even when it is unlikely to be needed. :e sympathetic to their grief, have tissue

ready, be patient, and allow them to cope.

Establ,s' a !lan

Mrs) 9ones I $ust !ant to ma0e sure that I understand your !ishes and am honoring them) What I

heard is that you !ant us to continue to aggressively treat your infection !ith antibiotics and

your 0idney failure !ith the dialysis) .o!ever* if you !ere to die* you do not !ant us to beginCP2 or life support) I !ill ma0e a note of your !ishes in the chart so everyone caring for you

!ill honor them) .o!ever* if you should change you mind* I can al!ays change this order) -ou

can let anyone on the team 0no! if you have any 3uestions or !ant to rethin0 this plan)

Do+8ent,n2 DNR stat+s

Anly a physician can write a )KR orderJ at many institutions, only the attending physician can

write this order and they always must co0sign it. >owever, as the subintern, you may have a

2B


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patient initiate this conversation with you or even provide you with their advanced directive.

"fter you have established a )KR status with your patient, you must discuss this status with

your resident and attending. )ocumentation of )KR orders in the medical chart includes#

)ate and time.

*ention of prior advance directives.

Reason for the )KR order.

Kotification of the patient/s attending and other health care providers.

Kames of the patient or surrogate decision makers involved in the decision.

"ny modifications to the )KR order, as allowed per your institution.

)KR decisions for hospitali1ed patients should also be discussed verbally to all of the

appropriate health care providers for that particular patient, and should be included in a patient/s

sign0out.

2C


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SECTION (: TRANSITIONS OF CARE

"s a subintern, you will help coordinate discharge planning, sign out patients to the on call

teams, write off service notes on the last day of your rotation, and write cross coverage notes on

patients you took care of while on call. !t is vital to recogni1e the importance of these key

communication issues surrounding patient care so that you can develop skills and strategies toensure continuity of patient care and effective hand0offs. !n fact, communication failures are the

most common root cause of sentinel events ;unexpected occurrences involving death, seriousphysical or psychological injury, or the risk of these< reported to the Foint (ommission ;F(


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CHAPTER 1.: CROSS%CO&ERAGE

". #obert $u% MDIndiana &niversity 'chool of Medicine

Meenakshy -. Aiyer% MD

&niversity of Illinois Collee of Medicine at Peoria

HO TO RITE AND COMMUNICATE A SIGN%OUT

*edical sign0out is the process by which the physician going off duty transfers patient

information and patient care responsibilities to the physician coming on duty. !t is also called a

6hand off8 or 6change over8 and is a critical point in communication. wo mnemonics serve as6best practice8 formats used to standardi1e sign outs.

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S**A*R: S,t+at,on a


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o "nticipate any problems that may arise and what to do about them, using specific 6if0

then8 statements.

o 'ist what management steps have or have not worked in the past.

*ost hospitals are transitioning to electronic sign0out templates that should include all of the

above information. ou should use these if they are available. !t is not appropriate to sign outto follow up the results of studies completed during your shift. ou should try your best to

follow through the studies to avoid burdening the physician coming on duty.

Sa8(le $),tten S,2n*O+t

5$$2DDB

:ond, F *RP DD=Rm

* team, )r. Q ;pager CCC0DDDDypoxic in %R 0 (R showed pneumothoraxJ ( surgery placed chest tube0 sats

improved.

Woke up 5$3 and c$o left leg pain0 plain film w$ nondisplaced fracture0 ortho casted

(urrently alert and stable, chest tube removed at +* today and vitals stable with A2 sats

5DDH on 2' K(

Ather issues#

5. Renal failure likely dehydration00initially concerned about rhabdo ;(+O =DD0 now

decreasing and also r$o *! w$ troponins history0 watching for withdrawal but not giving prophylactic ativan as no

history of )s

*eds# morphine +(" ;he/s getting a basal rate but hasn/t used the demand withdrawalheparin DDDunits &Q !)

"ll# KO)" but KA K&"!)&SS ;renal dysfunctionowever, a few criticalelements need to be included in every off0service note.

)ocument the day and chief reason for admission.

)escribe the hospital course seuentially, highlighting clinical diagnoses and new

problems developed since admission, and treatments, both successful and unsuccessful.

)escribe briefly the patient/s condition on the day of transfer, including cognitive status,

cardiopulmonary status, mobility, and nutrition.

)ocument the diagnostic tests done with relevant findings.

)ocument all consultations and key recommendations.

'ist patient/s current medications.

&ummari1e the active issues related to patient care and your plans and rationale for each

issue.

)ocument the tasks to be completed and followed up by the oncoming service, including

laboratory data, consultation recommendations, and family meetings that need to be

arranged.

&tate relevant discussions you had with the patient, family or consultants. >ighlightrelevant psychosocial information ;e.g., complex family dynamics, family beliefs


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CHAPTER 12: DISCHARGE P!ANNING/ COUNSE!ING/ AND SUMMARY

(eather 4. (arrell% MD&niversity of *lorida Collee of Medicine

Michelle (orn% MD

&niversity of Mississippi 'chool of Medicine


"s a subintern, you will discharge patients from the acute care hospital setting to their homes or

other facilities, such as rehabilitation centers or nursing homes. %ach patient/s discharge should

follow specific steps to ensure patient safety and uality of patient care. Recogni1ing theimportance of discharge planning in patient care, in 2DD, the &ociety of >ospital *edicine

endorsed a checklist ;see F,2+)e 1< that includes the reuired and optional elements of the

discharge.

3B


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F,2+)e 1* Ieal ,s'a)2e of t'e ele)l7 (at,ent: a 'os(,tal,st 'e+,)e ele8ent o o(t,onal ele8ent

3C


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P!ANNING

his section deals with the key steps in the discharge planning process prior to and on the day of

discharge.

!),o) to Da7 of D,s'a)2e )ischarge planning begins at the time of hospital admission as you set therapeutic

endpoints for the inpatient portion of care. !f you do not anticipate that your patient willbe at baseline, start anticipating what she will need ;e.g., an elderly woman with severe

pneumonia may reuire temporary home oxygen


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On Da7 of D,s'a)2e

+erform medication reconciliation. *ost hospitals use a medication reconciliation form

that is a safety goal of the Foint (ommission ;F(ave your pharmacist print this formout for you as soon as you know the patient is being discharged, review the list, and

decide which medications to continue, change, or stop. :e specificS he nurses will use

this form as part of the patient/s instructions at the time of discharge.

Write discharge instructions, including the critical elements.

5. Referring and receiving providers

2. -ollow0up plans#a. )iagnostic ests already scheduled or needed ;list each one specifically U e.g.,

:*+, (:(, renal ultrasound etc.ome health care needs.

3. )iet

a. (hanges, restrictions of diet.. "ctivity instructions and restrictions

. *edications

a. Review of outpatient$admission medications.b. )ose, route of administration, refills.

c. Kew medications that were added.

d. *edications that patients should no longer take.e. *edications that were kept but doses were changed.

f. +atient education materials.

g. -ollow up plans for specific medications ;i.e., !KR testing for someone being

discharged on warfarin


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DISCHARGE COUNSE!ING: THE CRITICA! E!EMENTS

Ane of the many roles you will have as a physician is that of a patient educator. Whether it iscounseling a patient on how to use his insulin, how and when to take medications, or how to stop

smoking, you will be considered the expert. %xperience in providing counseling is critical to

developing expertise in this area.

our role as a health care provider is to make sure everything is in place for discharge, including

making sure the patient is aware of what is expected of him and what will occur at the time ofdischarge. Remember these critical elements when counseling your patient before discharge#

(ommunicate with the patient in a private environment, ideally free of distractions.

&pend time with patient prior to discharge to discuss the disease process, medication

changes, and important follow0ups. Gtili1e trained interpreters when language barriers

exist.

!nclude family members, when relevant, to identify their concerns and ensure that theyunderstand the key points regarding the patient/s illness.

Gse simple terms when discussing disease process with the patient so that he can

understand. %ncourage the patient to repeat back what he understood to help you assesshis comprehension.

)ocument patient education and understanding of the education.

:e available to answer any uestions the patient may have and educate the patient on

discharge instructions. Remember that nurses, social workers or case managers,

pharmacists, and ancillary staff are there to support and assist you in this matter.

+rovide important follow0up information to the patient and provide a 2$= call back

number to contact for uestions or concerns that may arise following discharge.

+rovide patient education materials whenever appropriate on the patient/s disease

process, smoking cessation, diet, exercise, etc.

%ducation is the key to compliance. %ven the most motivated, intelligent, and well0intendedpatient will not be able to comply if he does not understand your instructions. ou are not only

the healer but also the teacher for patients.

PREPARING A DISCHARGE SUMMARY

"n effective discharge summary provides the critical information to other caregivers necessaryto facilitate continuity of care and is often the only reliable information other health care

professionals receive about the patient/s hospitali1ation. herefore, it should be thoughtfully

written. he highest uality discharge summaries are usually done within 2 hours, are generally

2


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less than two pages, and contain pertinent data that concentrates upon discharge information

necessary to provide a smooth transition of care. >ospitals may provide a standardi1ed discharge

summary template. !f not, you should follow a consistent format when writing or dictating yourdischarge summaries. he key elements of the discharge summary are#

Date of A8,ss,on.

Date of D,s'a)2e.

A8,tt,n2 D,a2nos,s: his item is the condition that you feel is

responsible for the patient/s admission. !t is your working diagnosis, not the chiefcomplaint.

!),8a)7 D,s'a)2e D,a2nos,s: 'ist a specific diagnosis and not a

sign or symptom.

Seona)7 D,a2noses: !nclude all active medical problems

regardless of whether they were diagnosed this admission. ;"ctive medical problems

include any condition for which the patient may be receiving treatment.G( of metronidaAole and no! C) diff negative on =>BG)

3


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!nclude any major interventions, key findings and test results, and complications. &elf0

limited electrolyte abnormalities, minor medication adjustments, and routine fluid

administration are too detailed. -or hospitali1ations less than three days, two or threesentences will likely suffice.

Con,t,on at ,s'a)2e: ry to provide a brief functional and cognitive assessment ;e.g.,6ambulatory with walkerJ8 6stable but confused and reuires assistance with ")'s8ome8


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SECTION ): PRACTICA! NUTS AND BO!TS

%ffective time management skills are essential to working efficiently in the hospital and

maintaining a fulfilling personal life outside of medicine. o be a competent subintern you will

also need to be highly organi1ed. here are a variety of other skills that may not have come up in

the first three years of medical school, but will be necessary to be a successful physician. ouwill need to document your patient encounters accurately both in writing and using a new skill of

dictation. his section contains several necessary practicalities that may not have been addressedelsewhere.


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CHAPTER 1': ESSENTIA! TIME MANAGEMENT AND ORGANI#ATIONA!

SKI!!SCynthia (. ,edford% MD6hio 'tate &niversity Collee of Medicine

!nterns contribute more to patient care, are less stressed, and learn more when they are organi1edand efficient in their work. >ospital0based medicine occurs in a very fast paced and hectic

environment in which patients face life0threatening illness. ou can train yourself to be

organi1ed and make the most of your time.

De/elo( a S7ste8 fo) Kee(,n2 !at,ent Data O)2an,;e

Oey information for each patient should be summari1ed concisely and at your fingertips

whenever needed ;e.g., primary physician, family contacts, home and current

medications, past medical history, etc.


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'earn about beds, lines, euipment, masks and oxygen delivery systems.

'earn to perform procedures that might not be considered the usual task of the physician#

placing leads for an %O4, drawing an ":4, placing a peripheral !E, or administering arespiratory treatment.

Ta


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Ta


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CHAPTER 1(: TIPS FOR ORK0!IFE BA!ANCE


here is no single formula for obtaining a balanced life. ou need to be able to communicate,

plan, organi1e, delegate, and set limits effectively to achieve a satisfying, fulfilling, wellbalanced personal and professional life.

-igure out what really matters to you in life. &et priorities and drop unnecessary

activities. &et boundaries between work and home. When you leave work, do not

continue to think about work. urn off your work pager or cell phone. )o not recheckyour work email.

+rotect your private time, even if it is for a walk, bike ride, or pi11a night. (oordinate

times with your friends and your spouse or significant other.

&et goals for both your work and your personal life. *atch the number of personal goalsto work goals.

&chedule time for regular exercise. ake care of your physical health. !mplement a daily

practice of meditation.

4et organi1ed and delegate. :uild a support network. )o not be afraid to ask for help and

allow yourself to be helped. !f you have children, always have a back0up plan and an

emergency plan in place. )o not feel guilty about hiring help ;if that is an option


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)o not make promises you can/t keep. here will be family events or holidays that you

will not be able to attend.

'earn to say no to reuests that are not on your priority list.

"sk for help or advice when you need it.

D


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CHAPTER 1): A DO#EN PEAR!S TO KEEP YOUR PATIENTS SAFE

AKA: ASSUME NOTHING3

(eather 4. (arrell% MD&niversity of *lorida Collee of Medicine

he first principle of being an excellent physician is to assume nothing as the buck really doesstop with you. !ronically as the acting intern, you are the person everyone ;the team, nurses,

patients, consults< assumes is on top of all the details even though you have little authority to

make things happen. )etails in patient care can easily get overlooked or improperly prioriti1edbut can significantly improve patient safety if attended to on a daily basis.

+erform a line inventory. "sk yourself every day what tubes and lines your patients are

connected to and whether they still need them.

'ook at your patients/ skin ;all of it


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CHAPTER 1*: HAT TO DO HEN A PATIENT DIES4


As a s+b,nte)n 7o+ ,ll not be ()ono+n,n2 eat's no) f,ll,n2 o+t eat' e)t,f,ates. T',s

set,on ,s 8eant to ()e(a)e 7o+ fo) ,nte)ns',(.

$'o to Contat $'en Deat' O+)s

he patient/s family or other surrogate. ;his is an appropriate time to discuss an autopsy

with the patient/s family


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specific and not leave any doubt as to why it developed. -or example, 6respiratory failure8 is not

specific because many conditions can lead to respiratory failure, but 6multi0lobar pneumonia8 is

specific. %very other condition in the seuence of death in +art ! should directly cause the6immediate cause.8 Gse your best medical opinion to determine the 6immediate cause8 of death

and you can also use the ualifier 6probable8 if no definite diagnosis has been made.

!n +art !!, you will list other chronic diseases or other substance abuse, injury, or surgery that

may have adversely affected your former patient and contributed to their death. hese conditions

in +art !! may be unrelated to each other or causally related to each other.

he cause of death can include information provided by an autopsy. !t is crucial that the

underlying cause of death be as specific and precise as possible for statistical and research

purposes.

ou also will want to include on the certificate whether an autopsy was performed and whether

the findings were used to complete the cause of death. +lease specify who the pronouncing

physician is if different from the certifying physician.

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CHAPTER 1+: TIPS FOR DICTATING4


Man7 ,nst,t+t,ons o not allo st+ents to ,tate b+t t'ese t,(s 8a7 'el( ()e(a)e 7o+ fo)

,nte)ns',(.

(omplete your dictation as soon as possible after the operation, hospital course, office

visit, etc. when details are fresh in your memory.

4et an instruction card for your hospital/s system that gives you the codes to enter for the

specific type of dictation and other tips uniue to your system.

-ind a uiet location.

Argani1e your thoughts and jot down some notes to help you.

"void dictating from cell phone ;bad reception


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$'at ,f I Ma


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CHAPTER 1,: DOCUMENTING PROCEDURES

Michelle ')eet% MD#ush Medical 'chool of #ush &niversity

%very procedure that is performed, or attempted, should have several crucial elements

documented in the chart as outlined below.

Date an t,8e

!)oe+)e

%xample# Paracentesis

In,at,ons

%xample# Diagnosis and relief of abdominal distension

O(e)ato)s

Info)8e onsent;usually a standard statement

Documents

Medicine Sub I Primer