Family Medicine Inpatient Service (FMIS)

(MUCH OF THIS INFORMATION IS ALSO APPLICABLE TO THE HOSPITALIST MEDICINE SERVICE)

Yolanda is the Goddess who brings us food and coffee every morning to the resident room. Feel free to make your reasonable requests on a piece of paper and leave it on the cart for her to see.
RULE #1: IF YOU’RE NOT SURE ABOUT SOMETHING, ASK!
Dress is professional/casual. Lab coats are great for carrying pockets full of reference stuff (i.e. Scutpuppy). Scrubs are OK and common.
The Service consists of SCFM medical patients and SCFM and PCHC OB patients. If the patient has an SCFM upper level resident as their PCP, and the resident is in town, he or she should follow his or her own patient(s) along with the team. The intern’s primary role is the OB/Newborn Nursery service (SEE THE SECTIONS ON PRENATAL CARE, OBSTETRICS, AND NURSERY.) The second and third year residents will handle most of the medicine side of the house. If there are no patient’s on the OB service, the intern will help out with medicine, and vice versa.
At night and on the weekends we also cover the Pediatric Hospitalist service. If one of the Peds Hospitalist attendings is on-call, pediatric admissions should be discussed with them; otherwise they will be discussed with the SCFM attending.
Remember, YOU are the primary provider managing your patients. Act as if only you are taking care of the patients. Your upper level and attending will serve as backup and help.
Taking vacation while working on the FMIS is not allowed.
Patients admitted through the ER primarily with a gynecological problem can and should be managed by the FMIS.
Medicine admits done by the intern will be presented to and discussed with an upper level, who then presents them to the attending. As the year progresses, interns may present a patient to the attendings after first discussing the admission with the upper level. (OB patients are presented to the attending by the intern after they have presented to the upper level).
Medical evaluation on all of our 6100 psychiatry patients is required within 24 hours. Present these to the upper level for A/P. We only see SCFM pts and patients we were caring for in the hospital that were transferred there.
Determine code status and level of care on all patients at the time of admission (especially severely ill patients).
Request old hospital records on all patients right away (frequently already pulled by the ER doc). The very last digits on the MR number is the number of times a pt has been to SMC. Remember that for SCFM patients, you can always go over to our clinic and can Xerox the face sheet for a great summary of the patient’s medical problems, meds, etc.
On admit orders write “Inpatient” if full admit or “Observation” if you expect pt to stay 24hrs or less. Write “Admit to _____ floor, Residents/Dr (attending on call)-SCFM. Sign all orders with your name then a slash and write attending’s name-SCFM.
Admit orders include: (ADC VAANDIMLS)
Admit to (floor) and Residents/(attending-SCFM), Diagnosis, Condition, Vitals (usually routine), Allergies, Activity, Nursing, Diet, IVF, Meds, Labs, Special (studies and consults)
Dictate H&P (see Pg 40) within 24hrs of admission (hospital rule) and it will be transcribed and sent to the chart within 1 day. Getting it in the chart early is very helpful, especially if you have consulted a specialist and they will be by soon to see the patient. You do NOT need to specify where the patient goes on your admission dictation as the H&P will find its way to the chart. If you can’t find the H&P for some reason, you can call the transcription dept. via the operator OR you can find it in Clinical Messaging.
Morning report in the resident room starts at 7am weekdays & 7:30am weekends & holidays for residents only. Include overnight events in your report.
Attending rounds are generally 9-11 am. (This varies depending on the attending.) You should see all of your patients prior to attending rounds and be ready to present.
Mega Codes will take place in the ER with nursing staff one day of each week or month (arranged by Upper Level resident).
Cardiology rounds are Wednesdays at 7:30 am in the resident room. A Cardiology attending will usually be there so try to be on time. Feel free to bring interesting EKG’s on your patients.
Radiology rounds are Thursdays at 7:30am down in Radiology, in the room adjacent to the film room. Again, bring interesting imaging studies on your patients if you would like to review them with the Radiologist.
See ICU patients first – if the service is particularly busy, you may consider coming in and seeing them before morning report. Labs on patients in the ICU are drawn EARLY, like at 3:30am, and should be readily available when you come in early to round.
ICU Notes
Admit date, Hospital day #
Diagnoses: list here all the diagnoses this patient carries
Lines: (i.e. Central line left neck, peripheral lines right AC, etc.)
Drips: make sure to put IV fluid rates as well as meds, ie dobutamine
Meds: make sure to note on antibiotics how many days they’ve had
Allergies:
Prophylaxis: i.e. protonix and SCDs
MS:
SX: List here what you would under S of a SOAP note
VS: Tmax, blood pressure ranges, resp, pulse, vent settings, etc
PE:
CXR: ICU patients with resp problems generally have a CXR daily
Labs:
Nutirition:
Assessment and Plan: Here write out a detailed A/P by problem, generally arranged in order of importance.
Aim to get all progress notes done before noon so that new admits & procedures can be done in the afternoon.
Follow labs & x-rays closely. Read own x-rays and compare to old ones if possible. Copies of all chest x-rays done in the ICU will be on the view box in the ICU usually by 6am on the day that they are taken. Feel free to bring copies of interesting imaging studies to morning report in the resident room.
Try to call/consult specialists personally for better communication, education, & rapport. If you just write an order for the consult and submit it for the ward clerk to call, be specific yet brief on your reason for requesting the consult.
For psychiatric problems you can consult psych liaison (i.e. when you just want the patient to have info on ETOH cessation, to approve transfer to 6100, etc.) or consult Dr Webb (if you want help managing psych meds, deeming competence, etc.).
Try to sign verbal/telephone orders when rounding to reduce medical records incomplete work later…if unsigned & the patient is D/C’ed, it will show up in your pile down in the Doctors Incomplete office when you request your charts to be pulled.
Discharge Summary dictations (pg. 40) should be done at the time of discharge by the discharging physician. To make this easier on your fellow residents who might be doing discharges on the weekends, keep the Discharge Order Sheet up-to-date as the pt’s admission progresses. Write down diagnoses, medications, studies (preferably with a brief comment about results), etc., as they are known.
Periodically complete dictations/sign charts in Doctors Incomplete (next to doctor’s lounge on 1^st floor). Call beforehand to have charts pulled (5180). You have access to this area 24 hours a day via the Doctor’s Lounge. Technically, you can’t take the charts out of that office.
For procedures, get signed consent, write a procedure note, & remember to record in your personal procedure log in New Innovations. Procedures require supervision by an experienced upper level and/or attending.
Sample Procedure Note:
Pre-Op Dx: Right Pleural effusion
Post-Op Dx: Right Pleural effusion, Empyema
Procedure: Right Thoracentesis
Surgeon: (Your Name)
Attending: (Supervising Attending and/or Upper Level)
Anesthesia: Local. 2% Lidocaine 4ccs
Findings: Skin prepped in usual fashion with betadine and skin anesthetized with local anesthetic. Using thoracentesis tray with large vacutainer, 500cc thick purulent fluid drained from right pleural space without complications.
Specimens: Pleural fluid sent for gram stain, culture, cell count, AFB, protein, glucose, LDH, pH, amylase, triglycerides, and cytology.
EBL: None
Condition: Stable on medical ward.
Dispo: Check CXR. Await lab results.
Post-Op assessment & note is recommended on all of our pts.
Keep patients & families up to date & informed of findings, A/P. It is not uncommon to have to schedule family meetings. Remember also that you can always request an Ethics Consult if you are dealing with very difficult patient issues. Hospice consults are very helpful with terminal patients who are going home (make sure you inform the patient before ordering this).
For continuity of care, you should request that the Discharge Order sheet be faxed to the patient’s PCP (or do it yourself). If the patient has an appointment for follow up with their PCP, the discharge sheet will likely be all they have to work with. A detailed discharge sheet is essential, they use them to help ICD9 code the patient’s hospital stay and it helps you dictate your D/C summary. It is very nice at the end of your D/C dictations to also tell the transcriptionist to please send a copy of the Discharge Summary to the PCP, but this may not be transcribed or sent for up to a couple weeks.
SCFM pts must have a hospital f/u appt with a team member who cared for the pt in the hospital. Patients have better follow up if you can actually call the clinic for them prior to D/C and get the appointment scheduled and listed on the discharge order sheet. Copy D/C sheet to go in patient’s file in clinic (it’s easy to forget what medicines they left on).
When discharging SCFM patients to the Nursing Home call Nancy and get a name of the resident who will assume care. Check out with that person if possible.
At the end of the month write a detailed & thorough off-service note to help orient the next team on diagnoses, meds, course, assessment, & plan. For pts who have been on the service a particularly long time, an Interim Summary dictation may be better than an off service note as a courtesy for the person coming on to take the patient after you J. The main benefits of an interim summary dictation are that it’s generally faster to do and that the next resident can start their D/C summary from where you took off. However, the transcription dept will complain if we do Interim Summary dictations on all of our patients, so use this sparingly.
We work very hard to get all residents home after noon lecture when post-call. Make sure your fellow teammates get a thorough checkout on your patients.
End of the day check-out is at 5pm weekdays or at noon if going to clinic. Include: Name, Age, Admission dx, Chronic dxs, Meds, Things to do/check, Actions to take for problems (i.e. if spikes temp pan culture, if BP elevated try adding an ACE, etc), & code status.

Family Medicine Inpatient Service (FMIS)

(MUCH OF THIS INFORMATION IS ALSO APPLICABLE TO THE HOSPITALIST MEDICINE SERVICE)

Yolanda is the Goddess who brings us food and coffee every morning to the resident room. Feel free to make your reasonable requests on a piece of paper and leave it on the cart for her to see.

RULE #1: IF YOU’RE NOT SURE ABOUT SOMETHING, ASK!

Dress is professional/casual. Lab coats are great for carrying pockets full of reference stuff (i.e. Scutpuppy). Scrubs are OK and common.

At night and on the weekends we also cover the Pediatric Hospitalist service. If one of the Peds Hospitalist attendings is on-call, pediatric admissions should be discussed with them; otherwise they will be discussed with the SCFM attending.

Remember, YOU are the primary provider managing your patients. Act as if only you are taking care of the patients. Your upper level and attending will serve as backup and help.

Taking vacation while working on the FMIS is not allowed.

Patients admitted through the ER primarily with a gynecological problem can and should be managed by the FMIS.

Medical evaluation on all of our 6100 psychiatry patients is required within 24 hours. Present these to the upper level for A/P. We only see SCFM pts and patients we were caring for in the hospital that were transferred there.

Determine code status and level of care on all patients at the time of admission (especially severely ill patients).

On admit orders write “Inpatient” if full admit or “Observation” if you expect pt to stay 24hrs or less. Write “Admit to _____ floor, Residents/Dr (attending on call)-SCFM. Sign all orders with your name then a slash and write attending’s name-SCFM.

Admit orders include: (ADC VAANDIMLS)

Admit to (floor) and Residents/(attending-SCFM), Diagnosis, Condition, Vitals (usually routine), Allergies, Activity, Nursing, Diet, IVF, Meds, Labs, Special (studies and consults)

Morning report in the resident room starts at 7am weekdays & 7:30am weekends & holidays for residents only. Include overnight events in your report.

Attending rounds are generally 9-11 am. (This varies depending on the attending.) You should see all of your patients prior to attending rounds and be ready to present.

Mega Codes will take place in the ER with nursing staff one day of each week or month (arranged by Upper Level resident).

Cardiology rounds are Wednesdays at 7:30 am in the resident room. A Cardiology attending will usually be there so try to be on time. Feel free to bring interesting EKG’s on your patients.

Radiology rounds are Thursdays at 7:30am down in Radiology, in the room adjacent to the film room. Again, bring interesting imaging studies on your patients if you would like to review them with the Radiologist.

See ICU patients first – if the service is particularly busy, you may consider coming in and seeing them before morning report. Labs on patients in the ICU are drawn EARLY, like at 3:30am, and should be readily available when you come in early to round.

ICU Notes

Admit date, Hospital day #

Diagnoses: list here all the diagnoses this patient carries

Lines: (i.e. Central line left neck, peripheral lines right AC, etc.)

Drips: make sure to put IV fluid rates as well as meds, ie dobutamine

Meds: make sure to note on antibiotics how many days they’ve had

Allergies:

Prophylaxis: i.e. protonix and SCDs

MS:

SX: List here what you would under S of a SOAP note

VS: Tmax, blood pressure ranges, resp, pulse, vent settings, etc

PE:

CXR: ICU patients with resp problems generally have a CXR daily

Labs:

Nutirition:

Assessment and Plan: Here write out a detailed A/P by problem, generally arranged in order of importance.

Aim to get all progress notes done before noon so that new admits & procedures can be done in the afternoon.

Try to call/consult specialists personally for better communication, education, & rapport. If you just write an order for the consult and submit it for the ward clerk to call, be specific yet brief on your reason for requesting the consult.

For psychiatric problems you can consult psych liaison (i.e. when you just want the patient to have info on ETOH cessation, to approve transfer to 6100, etc.) or consult Dr Webb (if you want help managing psych meds, deeming competence, etc.).

Try to sign verbal/telephone orders when rounding to reduce medical records incomplete work later…if unsigned & the patient is D/C’ed, it will show up in your pile down in the Doctors Incomplete office when you request your charts to be pulled.

Periodically complete dictations/sign charts in Doctors Incomplete (next to doctor’s lounge on 1st floor). Call beforehand to have charts pulled (5180). You have access to this area 24 hours a day via the Doctor’s Lounge. Technically, you can’t take the charts out of that office.

For procedures, get signed consent, write a procedure note, & remember to record in your personal procedure log in New Innovations. Procedures require supervision by an experienced upper level and/or attending.

Sample Procedure Note:

Pre-Op Dx: Right Pleural effusion

Post-Op Dx: Right Pleural effusion, Empyema

Procedure: Right Thoracentesis

Surgeon: (Your Name)

Attending: (Supervising Attending and/or Upper Level)

Anesthesia: Local. 2% Lidocaine 4ccs

Findings: Skin prepped in usual fashion with betadine and skin anesthetized with local anesthetic. Using thoracentesis tray with large vacutainer, 500cc thick purulent fluid drained from right pleural space without complications.

Specimens: Pleural fluid sent for gram stain, culture, cell count, AFB, protein, glucose, LDH, pH, amylase, triglycerides, and cytology.

EBL: None

Condition: Stable on medical ward.

Dispo: Check CXR. Await lab results.

Post-Op assessment & note is recommended on all of our pts.

When discharging SCFM patients to the Nursing Home call Nancy and get a name of the resident who will assume care. Check out with that person if possible.

We work very hard to get all residents home after noon lecture when post-call. Make sure your fellow teammates get a thorough checkout on your patients.

End of the day check-out is at 5pm weekdays or at noon if going to clinic. Include: Name, Age, Admission dx, Chronic dxs, Meds, Things to do/check, Actions to take for problems (i.e. if spikes temp pan culture, if BP elevated try adding an ACE, etc), & code status.

Periodically complete dictations/sign charts in Doctors Incomplete (next to doctor’s lounge on 1^st floor). Call beforehand to have charts pulled (5180). You have access to this area 24 hours a day via the Doctor’s Lounge. Technically, you can’t take the charts out of that office.