Harborview Medicine 665
Expectations for Ward Students

Expectations

• Enthusiastic participation in clinical and teaching activities.
• Respect for Harborview's mission to provide outstanding health care to all regardless of social station or ability to pay.
• Professional demeanor and behavior; HMC Photo I.D. is required at all times.
• Take overnight call and admit every fifth night.
• Provide direct patient care for 1-4 patients at a time. Because length of stay is often very short, you may want to work-up 2 patients on overnight call or take an admission on short-call.
• Suggested on-call activities:
  • Admit 1 or 2 patients
  • 1 complete admission note (see outline below) completed before morning rounds. If a second patient is admitted, second note can be more directed or you can simply start writing progress notes on the post-call day
  • 1 hour of reading about pathophysiology, differential diagnosis, management, etc.
  • Active participation in team activities: cross-cover, codes, ER patient evaluation, etc.
  • 4 hours of sleep.
• Strive toward primary responsibility for patient care:
  • Review primary patient data: medical record, radiographs, lab results, etc.
  • Write all but emergent orders
  • Participate in diagnostic and treatment planning
  • Represent (and speak for) your team whenever your patient is discussed
  • Educate your team regarding pathophysiology, diagnosis or managment.
• Pre-round: allow 15-20 minutes per patient before Work Rounds to review data in CIS, ORCA and paper chart; review overnight events; perform directed interviews and exams; and discuss a plan for the day with your intern.
• Brief, focused, well-organized presentations, delivered from memory (see below).
• Timely completion of daily medical record notes. Entering cross-cover sign-out information into CORES is also very helpful.
• Opportunistic and tireless educational attitude. At Harborview, we appreciate the stimulation of working with students who are highly motivated to improve their skills, take advantage of learning opportunities, and actively participate in patient care. You should seek hands-on, practical experience in patient evaluation and management. Try to learn something from every patient on your team. See and do as much as you can. Rather than sequestering yourself in the library, you will learn more by hanging out with your team and contributing to patient care. Take advantage of all opportunities to ask questions, examine patients, and educate your team.
• Give Dr. Sheffield a copy (or cc: via ORCA) of at least 1 admission note each week.
• We expect the Harborview wards to be a challenging but highly stimulating and fun work environment. If you are encountering problems with the educational environment, please alert your Resident, Attending, Chief Resident, John Sheffield, or Samantha Groom to problems as early as possible.

Suggested Presentation Guidelines

(See also "Oral Presentation Benchmarks" at http://courses.washington.edu/med665/ under "Student Info.")

Post-call work rounds

• The purpose of Work Rounds is to quickly set a management plan for the day. Because these rounds must end by 9:30 AM, you must be highly selective regarding the content of your presentations. Please include ONLY information crucial for management. Some important information (secondary PMH issues, FH, some SH, and ROS) must be omitted.
• The goal for the rotation is 3-5 minutes in length. Practice on call with your resident.
• Make eye contact. Presenting from memory makes this easier. Please do not read from write-ups or cards except when reviewing medications, vital signs, and lab results.
• Suggested outline (subject to vary with input from your resident and attending):
• Chief complaint (Identifying information, problem, duration).
• HPI (include relevant FH, SH, and pertinent negatives).
• Active/Relevant PMH (can omit if mentioned in CC or first line of HPI).
• Medications and Allergies.
• Physical Exam – general appearance, vital signs, pertinent findings.
• Labs – only pertinent results.
• Summary Statement.
• Assessment and Plan, by problem. For each major problem, state what you think is going on and why, give a realistic differential diagnosis (if relevant), and then outline your management plan. Then go on to problem 2, etc., but only address the major problems.
• If you are able to give a tight, concise, well-organized presentation that summarizes crucial information and omits data of lesser importance, your team will conclude that you are doing an excellent job. If your attending has questions after you are done, that does not necessarily mean you should have given more information.

Daily work rounds

• 1-3 minutes in length.
• Suggested outline:
• Intro: “This is day #4 for our 34-year-old woman with cellulitis.”
• Overnight Events: key symptoms, signs, lab results, procedures, etc.
• Interval Exam – vital signs, pertinent findings.
• Labs
• Assessment and Plan for the Day, by problem.

Suggestions for Write-Ups

(See also "Guidelines for Written History and Physicals" at http://courses.washington.edu/med665/ under "Student Info.")

Recommendations for Using ORCA PowerNote

• All of your notes will be typed into ORCA as "Medicine – Inpatient Record." You may use PowerNote, Simple Note or the direct "Medicine – Inpatient Record" template.
• If you choose PowerNote, be aware that it is non-intuitive and contains headers for every conceivable note ever written. Please use only the headers necessary for ward medicine notes.
• Use the free text option ("What box") for the ENTIRE Physical Exam. PowerNote headers are erroneous and should NOT be followed. Do NOT point and click to document your exam.
• Sign your notes and refer them to your attendings for review ("cc").
• Please send admission notes to clinic primary care providers for review and also send 1 admit note per week to Dr Sheffield so he can give you feedback.

Admission

• Your note should be the most comprehensive account of your patient's acute illness, prior history, exam, and management plan. Consultants WILL read your note.
• You may use PowerNote, Simple Note, or the Medicine – Inpatient Record template.
• In the HPI, use a consistent time reference (usually “prior to admission” – PTA) when outlining chronology. Include pertinent negatives relevant to the differential diagnosis at the end of the HPI.
• Do NOT include a Problem List. (Problem Lists are useful for clinic notes and discharge summaries.)
• PMH: include complete details and use outline form so readers can find details easily. For example, a history of COPD could mention PFTs, prior ABGs, and prior use of corticosteroids.
• Review of Systems: every patient deserves a complete review of systems (not necessary to repeat symptoms listed in HPI)
• Physical Examination – every patient admitted to the Medicine Service deserves a complete screening physical exam, including neurological. For systems relevant to the presenting problems, a more detailed exam is appropriate.
• Assessment and Plan – give A & P for each problem separately, beginning with the most important problem. For example:
  1. Problem (diagnosis, symptom, sign, or lab result, being as precise as you can, based on information available). Begin with a focused discussion of the problem outlining what you think is going on and its severity. For problems with a differential diagnosis, you should mention the most likely explanation first then emphasize realistic or do-not-miss alternatives. You may want to discuss the rationale for the diagnostic and therapeutic plan briefly. For unusual or especially interesting problems, you may also include educational information from your reading here. (Note that we are NOT interested in reading information copied and pasted from UptoDate or branching diagram approaches to very common problems.)

  Plan:

  • List your diagnostic and therapeutic plan in bullets, and be specific
  • This makes your note easier to read and more accessible for people in a hurry (i.e., everyone)

  2. Problem the next. Ditto above. As you move to less important problems, you won't have as much to say. For very chronic problems, you may simply say:

     Plan: Continue current outpatient management with …..

  3. Any problem requiring orders should be addressed in your admission A/P.

Daily Progress

• The "Medicine-Inpatient Record" template is the preferred note
• Hospital Day – automatically imported
• CC: age, sex, major problem(s) being addressed in hospital (as above in Daily Work Rounds presentations)
• Interval History: Overnight events, status of major ongoing symptoms, pertinent ROS.

  NOTE: “No events” is NOT acceptable.

• Meds/Infusions/PRN: accurately imported from CIS for you
• Exam: Problem-focused exam as appropriate
• Labs: routine chemistries and heme results are automatically imported
• A/P: Revised daily for accuracy and precision

Primer for HMC medical information systems

ORCA

• Electronic medical record, containing all clinic and ward notes. You will chart here.

MINDscape

• Duplicates ORCA but easier to navigate. Cardiology test results (ECG, ECHO) appear here first. (You cannot chart directly into MINDscape.)

CIS

• Real-time clinical data including vital signs, medication cardex, and lab results.
• Social Work, Nursing, and PT/OT notes are here. (NOTE: if you want to find out what happened overnight, read the nursing notes.)

CORES

• A parallel universe utilized for rounding and cross-cover and sign-out.
• CORES imports vital signs and lab results, but you have to input (and update) problem lists, med lists, and sign-out plans.

Paper Chart

• Enter and flag medical orders here.
• Contains loose papers from the ER (ambulance sheets, ER notes, etc.) before they are scanned.
• Occasionally used by some consulting services to give advice and chart progress.