Category: Residency

Admission & Orders

Ugh, poop on this.
Admission orders is one of those things where you need to know what to put in, but because every hospital is different there will be different important things to add. Also, who adds what changes based on what type of hospital you are in. Sometimes the residents do all of it. Sometimes the attending does part of it and the residents do the rest. Sometimes the ED doctors do some of them. It really all depends. But as a resident, you need to know what is important on what to add during admission orders.

First things First…

You need to accept the patient. Whether your attending does that for you or not doesn’t matter. Communicating with the ED doctors about accepting or declining admission is important. Once you have established the admission (or observation) then you can move forward with the next steps.

Then you do your regular chart review of a new patient. Write down what you need to know about the patient from what is in the ED note and any past/prior visits. You’ll want vitals, what was done/found, what meds were given, etc.

Write down what you want to ask the patient that you don’t see in the chart review to help clarify as well. Then go and see the patient. You can start putting in some orders before hand, but mostly you’ll want to see the patient first.

Orders

After seeing the patient you need to put in orders. You can do this prior to staffing with your attending or you can wait until after. If you wait, I suggest calling right away.

Here are 3 mnemonics to help remember orders:

I personally go off the headers under the orders tab in MEDITECH to remember. Since I can’t find an effective picture online OR take a decent photo from my computer screen (my stupid work computer won’t let me screenshot UGH), I’ll write the order below.

  • Consults
  • Diet- regular, heart healthy, carb controlled (for diabetics), renal, full liquids, clear liquids, NPO, etc
  • Labs- you’ll need to order what other tests you would like to investigate with AND maintenance labs for the following day (i.e. H/H vs CBC, BMP vs just an electrolyte).
  • Meds- what you are ordering during their inpatient stay
  • Nursing orders- includes SCD’s (compression devices/VTE prophylaxis), vitals, activity, shower privileges, home med lists, fall or seizure precautions, and any treatment clarifications
  • Radiology- any and all imaging studies
  • Rehab- this is for your PT, OT, and ST orders. If patient is above 65 they automatically should be getting at least PT. If your patient is struggling with household tasks or fine motor movements OT should be ordered.
  • Respiratory therapy- Your respiratory medications will be ordered under medications. But here is for oxygen monitoring/weaning, or suctioning, etc.
  • Med Req- I always do this last. I usually wait until the nurses are able to obtain the patient’s home medication list, review it, and place it in the chart. Then I can go in and re-order the medications that they take from home or hold what I don’t want them taking. If the patient happens to have their medication list or the bottles of medications with them when I am admitting them, I will just place this information in myself.
  • Also during admissions, I will update any allergies, PMHx, SHx, Family Hx, and Social Hx into the chart.
  • Oh, and don’t forget to add code status if that is your job to obtain and place! At my institution it is the admitting physician’s job (aka admitting resident) to verify with the patient and place in the order.

So yes, it can be a lot to remember. Some programs have prompts for you to help you remember. After a while you just remember what to do. At this point (7 months in) I remember most of what I need to. Anything that I forget I will usually remember after starting to type my note.

I know this is a short post and not the most helpful thing, but I do hope it helps give you some clarification. Remember, this will come with time and repetition. IF you are a medical student trying to learn what you need to put under plans, learning these orders and placing them under your diagnosis headings can be helpful in teaching you important management.

Cheers!

My First Intern Rotation: Wards

Hey ya’ll,

Long time no chat. Life has been crazy busy. Lots of new experiences.

Since we last spoke, I did the whole not matching thing, then SOAPed. I graduated medical school (yay!), moved from Missouri to Florida, and started as a transitional year intern through an IM program.

And I gotta tell ya, they threw me right in.

When I initially planned to write this it was going to be directly after my first rotation. However, life. Yea that thing, it happened. So now I’m doing it 5 months into residency. I would say don’t judge but you’ll do it anyways lol.

Daily Schedule:

Anywho, here is how my day typically would go:

5:00 AM: alarm would go off. But ya girl likes her sleep. So I hit snooze until like 5:30

5:30-6AM: Get ready, make coffee, feed cat, and drive to work. Thankfully I only live 5 minutes away so I can be super lazy.

6AM: Signout from night team. We receive updates about our team’s patients from overnight. Also split up any admissions amongst the team.

  • We have 3 teaching teams at my hospital. A, B, C (I know so original). Any other hospitalists do not use residents. Residents typically stick to 1 team while on rotation (2-6 weeks depending on your schedule). The hospitalists will rotate through depending on when their on/off days are. Usually, we stick with the same attending the entire time they are on.
  • I.e. Dr. Brown, attending, is working 11 days straight. Team A will work with him during this whole time until Dr. Smith comes on for 8 days on team A. etc.

6:10-6:20ish AM Signout ends. If we are on rapid call (rapid response team) we stay in the hospital. If not, we all head over to our resident lounge to work for the day.

End of signout- 8:00AM/8:30AM: Pre-charting. I will go over this later if you are curious about what this entails.

Around 8/8:30-10:30AM: See my patients in person/resident rounds. Then come back and pre-write/prep my charts.

10:30 AM (variable depending on attending, actually anywhere between 10-11:30) is attending rounds. Depending on if it is table rounds, walking rounds, or bedside rounds will depend on the length. It is also very attending dependent on how much they choose to teach during this time.

  • Table rounds: Sit down and present/discuss patients while running the list.
  • Walking rounds: Walk through the halls while rounding. This allows the physician to decide to see the patient right then and there as well or if they prefer to see them later.
  • Bedside rounds: I hate these. You literally present in front of the patient. Its awkward for everyone including the patient. As an attending, don’t do this. Please.

Around 12:30 PM: Usually we have some form of didactics/noon report that starts at this time. So we need to be done rounding. If able to, we will put in orders before this time.

12:30-1PM: Protected learning time M/W/Th. (At my institution). On Tuesdays we have didactics from 12:30-4pm. So we don’t take new patients. If you are crafty you can try to do some of your notes during this time.

1-4PM: If unable to put in orders before, we put them in right after. Updating patients, answering nurse pages, putting in any additional orders, taking new consults, etc. At some point I step away from my computer to eat lunch. We stop taking consults at 4pm.

4PM-5:30PM Finishing up notes, filling out patient keeper (this is a written signout for our night team so they have a physical copy of our patient list), answering any pages, finish seeing admissions, etc.

5:30PM Signout to night team.

5:30-6PM We have to stay signed in to answer any issues/calls from nursing staff so the night team can get settled. If it is non-urgent it can be dealt with later or tomorrow.

Any time after this if my notes aren’t done, I stay until they are. Learning to be efficient so I don’t have to stay later is important so I can have that precious time after work eating/showering, decompressing, and most importantly… SLEEPING!

Because I’m a numbnuts I usually don’t fall asleep until 11 or midnight and then regret my life choices in the morning.

We work 6 days a week on wards.

What to look at during Pre-Charting:

Okay, so everyone does this differently. My program uses Meditech, so I usually go down the list of tabs from top to bottom. With time this gets quicker. If you have had your patients for more than a day or two it goes by quicker. Yes, there are some days where mentally I’m so foggy it is not quicker. Those days suck. I make more mistakes those days.

Good thing I’m an intern and have a senior double checking me. 🙂

  • First things first, get the list from your senior! This includes all your previous patients, any new admits, and then whatever else ends up being given to you. Usually the attending gets more admits overnight than what the residents are allowed to see. In that case you would find the H&P notes from the PA/NP’s. Those patients get put on the residents afterwards to continue to follow.
  • Then after adding all of your patients to whatever lists you have (I have my list on Meditech so I don’t have to comb through the large attending list and add it to my phone so nurses can page me), print zee list.
  • Then I chart check while I add my notes to my printed list. I put the important info on my sheet.
  • Check/list vitals. I put down the last recorded. If any abnormal vitals I write those down/times it occurred. (I.e. fever of 39.2’F at 0100)
  • Then I’s/O’s. Important for AKI (acute kidney injuries), dehydration, septic patients, HF patients, etc
  • Then I check labs. I add new labs. I also add any labs I’m trending (i.e. worrisome WBC, hgb, troponin, etc). You will learn how to use fishbones real quick after writing it down repeatedly for many patients, many many days in a row.
  • I check microbiology. This is where any cultures are. I add any changes/updates from these to my notes. (i.e. Blood Cx: NGx4d = no growth for 4 days)
  • I check for any new imaging studies and add those results
  • I check medications. Make sure if anything was added/changed or they were given anything extra at night (Like tylenol, ativan, haldol, etc)
  • Then I look at other provider notes, case management notes, any PT/OT/ST notes that are important. What is happening and what else do I need to be aware of?
  • Then lastly I prep my notes with this information.

Chart Prep:

At my program, all notes have to be started by 7 AM if you are on wards. Not sure why, but that’s what my seniors tell me.

For HPI, I usually put seen at bedside as first line. If I see them in their bedside chair I change it later. I add any acute events overnight if something happened. Like high blood sugar, if a rapid was called, if they were agitated overnight, anything that I need to keep track of. Then I put asterisks as a place holder to remind me to come back to it.

For the objective portion, I add in my labs and meds that auto-populate. I click off any boxes that need to be checked. Most of my physical exam will be unchanged. I carry forward my previous days exam for now. I will change it to be accurate once I get back to charting later.

For A/P, this gets carried over as well. I will look through my plan and add any new information from specialists, labs, imaging, remove what I don’t need, add new diagnoses, etc. This way it is prepped so all I have to do is go back and change/add what I need after rounds. If there is anything I need to double check I put asterisks next to it so I can make note of it and ask during rounds or check back later.

I then click off all the necessary quality tabs. Like BP, weight, tobacco cessation, adding the PCP, the appropriate consults taking care of the case, etc. Stuff that is needed for Medicare but since it’s harder to find out who is and isn’t Medicare we just do it for everyone. That way the attendings don’t get a nasty-gram about it not being done and then we don’t subsequently get said nasty-gram handed down to us.

Between Pre-charting and Attending Rounds:

So, after pre-charting I will go see my patients. I usually have 1 med student with me as an intern and possibly 1-3 pharmacy students with me. Makes me feel such important. Much big doctor lady.

There is a whole other rhyme and reason about teaching/monitoring med students on wards but I won’t get into that here.

I also make sure to check in with all my nurses to see if they need anything from me that I couldn’t get from the charting process. Or if something overnight occurred that wasn’t ever documented.

After seeing all my patients and adding/changing any orders that I need to do I will try to head back to the lounge to fill in the gaps of my notes. I prefer heading back to the lounge because we get access to a lot of free snacks and also I leave my coffee there most of the time if I don’t bring it with my on my rounds.

I then add in/finish my HPI portion of the note. Progress note HPI’s are very very short. Unless something happened overnight or the patient has a lot of complaints that I may need to address there isn’t much to add. I also fill in/fix/update my physical exam. I chat with my senior (if they are available) for anything we may want to bring up in rounds or if I should wait to order something/consult someone until attending rounds. I will update my plan if I am able to at this time.

Order of Importance:

Okay. As a resident (and later as an attending) you will have many things to do. You will have many people pulling you in all sorts of directions that to them, their issue is urgent. But it may (and likely) won’t be urgent for you.

You need to learn what needs to be done first and what can be attended to later. So here is the order of importance you should try to stick to/follow:

  1. Seeing your patients. You can’t do much/make a clinical decision without first evaluating the patient.
  2. Putting in orders. Your staff cannot help take care of the patient appropriately if you do not put in the correct orders in a timely matter. Things change day by day in the hospital. For some people, things change quickly. For most it is small changes. Or it could be a bunch of small changes that turn out to be a giant beehive mess of shit to follow/monitor but that’s another story. Put in your orders in an appropriate amount of time.
  3. Contacting consultants/specialists/other residents. If you have questions for consultants you need to make sure you put your communication out there early enough. Other specialists and attendings do not have to get to you right away; they are on their own schedule. Do yourself a favor and try to get communication in early.
  4. Discharge planning/set up. Getting your discharge orders in early, making sure the medication req is done, new prescriptions are in, and any forms are signed for patients who are being discharged. Talking to case management usually once in the morning and later on throughout the day to stay in touch/find out the accuracy of the stage of getting your patients home is important. Getting someone to rehab/SNF/LTAC/hospice/transfers can take days. Sometimes weeks (but I hope not for your sake). Making sure all your ducks are in a row early enough so you are not stopping the process/stalling the process is very important.
  5. Answering nursing pages/questions and pharmacy questions/pages. Some of these things will need to be moved up in acuity depending on the question/page. Otherwise, if you are able to quickly answer do so. But if you need to concentrate on what you are doing and the message isn’t urgent and doesn’t affect care right away you can answer it later. Just don’t be a dick and make sure you answer.
  6. Following up on patients/family. Updating the patient is important. Although you do not owe a patients’ family answers. You are only obligated to communicate with the patient provided they are oriented appropriately and have capacity. Otherwise it is the POA/medical decision maker. Just because the family wants to know doesn’t mean the patient wants them to know. You need to clear it with patients first before you tell family anything. Also, patients can update their families. As the resident you do not need to run to talk to a patient’s family every time they demand it. Learned my lesson the hard way with this one.
  7. Making sure appropriate labs are ordered for the next day.
  8. And lastly: notes. This is the very last thing. You must finish notes by the end of the day. The earlier the better. But that is a time management thing. Which is why I usually try to do most of my charting in the morning. It makes it less daunting to do it all at once, and easier to remember things if I am not waiting to the end of the day to write it all down. Your notes are not more important than anything else up above. If you have to stay late or do them at home, then that is what you have to do.

Patient Caps:

As an intern, I have a cap of 10 patients per day. I typically start off anywhere between 7-9 patients with room for admissions during the day. As soon as a patient is discharged they no longer count as an active patient. Thus, I can receive a new patient/admission in it’s place even if they haven’t left the building.

Ya, it sucks.

But it is what it is.

Because my first ever intern rotation was inpatient wards I was lucky enough to be eased into it. I started with 3 patients, then within a week or so I was up to 5 patients. By the time I hit 5 patients it was hard. I struggled mucho grande with extra extra whip on top.

By the end of my first rotation I had hit 10 patients consecutively. By the second time I hit wards, thankfully I had that buffer at first because I hit 10 patients with the ground running. My co-intern wasn’t so lucky as it was his first wards during my second time around. So he got hit with 8-9 patients right off the bat without having any prior wards experience.

Each intern has a senior at my program (on wards anyways). If it is 1 intern:1 senior, intern can take up to 10 patients, which the senior follows all 10 patients. The senior can also take 4 additional patients. If I have patients that I am not doing anything with or I am not learning anything, I will give them to my senior or back to the attending. (I.e. waiting for placement and it is taking forever).

If it is 2 interns:1 senior each intern can take 10. The senior has a cap of 20, as in they follow all 10 patients of each intern. But then they don’t take anything additional.

Expect your senior to monitor you very very closely at first, regardless of if you had wards before or not. They don’t know you, how you work, or where you have lapses/gaps in your abilities yet. Once they work with you for a bit they will usually relax and not be so on top of you. Although if you suck they won’t. Just saying.

AAAnd I think that’s all I will put in this post. I want to thank the med school advisor who sent me a fantabulous email who jump started my interest in writing again. I appreciate you and your kind words.

But also, I was just too lazy to write more content. Anywho, Cheers!