Interview patients as resident/attending assigns

• Write complete H & P on no more than two new admits in one day (and two on-call on weeknights).

• Be prepared to give a precise and comprehensive presentation of the patient’s case to the team, and have pertinent data available for the team’s review. Try to gather all data prior to rounds.

• You are responsible for your assigned call days. If you have a major problem, you are responsible to find a fellow student to cover your call, and to inform the resident on call with you and Lois Larry of the change. Your grade will reflect your attentiveness to your on-call duties.

• Call begins at 4:30 p.m. on weekdays, and at 8:00 a.m. on weekends and holidays. You are expected to be in the hospital when you are on call.

• On weekdays, around 4:45 p.m., you should page the resident on-call and give your name and beeper number. You may do this through the UAB Paging Operator at 4-3411.

• While on call, you will be expected to see new admissions as well as consults to the general hospital and emergency department as your resident directs. Your resident will decide which patients you write-up.

• The morning following call, you are expected to attend morning report. Be prepared to give a concise presentation of the patients you worked up.

• Assist in work-up of new admissions as above

• Typically be responsible for following and charting on no more than five patients at a time, (if some patients become less acute, the number of patients may increase).

• You are expected to be available from 8:00 a.m.-5 p.m. Monday through Friday. Your attending may extend these hours as needed to complete work, rounds, etc.

Should include the above (as daily progress notes), but also a list containing diagnoses, ICD-IX Diagnostic Code in parentheses after the diagnoses, current medications, allergies, any special problems to watch for, labs or other studies to follow-up during the weekend.

List diagnoses, interventions, patient’s responses to interventions, prognosis, plans for disposition, brief summary of hospital course by problem list. This is a courtesy to the practitioner who follows you.

At discharge you should write in the last page of the chart:

Admission and D/C dates

• Multiaxial diagnosis

• Procedures

• Consults

• Disposition

• Condition at discharge

• D/C diet

• D/C activities

• D/C medications; including prescriptions written, # dispensed, # refills

• F/U appointments

• Any pertinent D/C labs (e.g. lithium levels, CBC, etc.)

• Include a notation if you dictated the D/C summary and date dictated.

You are expected to dictate only on patients you followed. Use the format provided in your YELLOW BOOKLET, Psychiatric Record Keeping. Your resident or attending will review these with you.

• The medical record is a legal document, and is subject to review by Quality Assurance, various review boards, third party payers, other practitioners and at times by the courts. As such, it should be legible, concise, and accurate. If an error is made, draw one single line through it. Write error and your initials.

• It’s purpose is to reflect, as accurately as possible, the evaluation and management of a patient’s illness(es).

• Any entry into a chart becomes a permanent part of the record on a patient, and as such, should be carefully considered.

• Do not document Incident Reports in the medical record. Incident Reports are for internal communication about problems that occur in the course of patient care.

• Do not express feelings or derogatory comments about other care-providers in the medical record. Doing so puts not only the other person in jeopardy, but also you and the team. There are other avenues for expressing your concerns and feelings.

• Various forms of documentation serve specific purposes, but taken together should constitute a coherent history of a given episode of illness. What follow is a very basic outline of the purpose and logic behind various types of documentation that physicians, psychiatrists, in particular, do.

1. Admission History and Physical (H &P)

   Reflects as accurately as possible the patient’s presenting symptoms, his past history (medical and family history, social history [including developmental, birth order, education, significant attachments, social support system], legal history, substance use history, physical exam, systems review, lab data, and multiaxial diagnosis and treatment plans.

    

2. Daily Progress Notes

Reflect the ongoing assessment and management of the patient’s illness including:

• New data as they are acquired

• History, observations, lab, radiographic, consultations, testing

• A rational synthesis of the data into a diagnostic formulation

• The rationale for therapeutic interventions, treatment goals

• The patient’s response to interventions

• Includes positive and negative responses (e.g. improvement, or complications, medication side effects)

• The plan for future management

• Prognosis

3. Discharge Notes

• Serve to record in the chart a brief synopsis of the patient’s hospital course, status at discharge, and clear plans for ongoing care (See the outline under DOCUMENTATION, D/C NOTES).

• It leaves a record of important D/C data in case the patient is readmitted prior to transcription of the C/D summary, and is a courtesy to the practitioner who my see the patient next.

• It also can serve as a helpful outline for dictating the D/C summary.

4. Weekend Notes (or pre-holiday notes)

   A basic outline of patient’s diagnosis, medications, allergies, anticipated problems, pending labs for the attending covering during the team’s absence

5. Discharge Summaries

This document is a culmination of all your previous charting, and should record a synthesis of the patient’s problems, what you did to evaluate and manage them during this hospitalization the patient’s response, and a plan for ongoing care.

It includes:

• The patient’s presenting illness, his symptoms, signs, history of his illness

• How you evaluated the patient’s illness

• How you made sense of what you found

• What you did to treat the patient and why you did it

• How the patient responded to what you did

• How the patient will be managed in the future

If you’ve done your previous charting efficiently, all the data you need should be readily available for dictation of the D/C Summary.

The outline of the D/C Note is a good format, but in the D/C Summary, you will include a "Hospital Course" section for each problem. Make it brief!! It should not be a recounting of daily events, but a summary that includes the above data in a coherent, concise format.

At the end of the dictation, be sure to dictate the names and addresses of persons who will need a copy of the D/C Summary (e.g. referring M.D., those who will see the patient in follow-up).