note

note

note

note

note

PT, ward

Consults

Studies

D/C?

Orders

Check

Calls

Misc

Sign Out

Date:

ScutHow to Prioritize It. After all the patients on the service have been presented, there will be time to attack the scut or to-do items for your patient. Taking care of scut is the responsibility of the interns, but they often rely on medical students to help out and will delegate some scut to you. As an MS3, youll rarely have more than 2 or 3 patients to cover. As an MS4, you may have as many as 6 or 7, sometimes more on a heavy service, and youre on your own (although your R2 will help you). This sample scut sheet is designed for a clipboard. Each row indicates a patient, and patients are listed from the bottom of the page upward, starting with the sickest patients (usually in the ICU), followed by less sick (TCU or, at SFGH, 4Bnot in the unit, but high level nursing care), followed by floor patients, usually clumped together by location, i.e. patients all on the same floor listed together. Each column is a type of scut item. Items to the left have higher priority and should be done first, followed by items in the next column, etc. Calling a Consult. Youll notice calling consults is done first. Examples include calling infectious disease service to get advice on the choice of antibiotics, or calling renal to help assess a patient in acute renal failure, etc. As a general rule, you should contact the consult team before noon, unless the patient happens to get sick and needs urgent attention late in the day. Fellows expect to hear about new cases as early as possible. Some fellows and consult attendings refuse to take calls from medical students. This is not rudenessjust an impatience with student ignorance. If your resident asks you to call a consult service, you must ensure you can state precisely what question you are asking. If its not self-evident to you, it will not be self-evident to the consultant. Also, ask your resident if she wants to hear back with a phone call, or if she just wants to check the consult note in the chart later. Be prepared to give the consultant a mini-presentation about the patient. This includes basic information such as patient name, medical record number, and location; your teams attending and resident and their pager numbers; most recent vitals and lab values; and background information, such as an abbreviated version of the initial history and physical and the main events of the hospital course to date. Get all of the above at your fingertips before you call. Once youve explained the nature of the consult and given the basic information, and the consultant confirms that he will see the patient, find out when the team can expect to hear back regarding his assessment. I often finished the conversation with, Thanks. And in case my resident asks me, can you tell me when you think you might have recommendations for us? After consults, the next item is ordering1 studies, e.g. X-rays, CT scans, etc. The sooner these are ordered, the more likely the patient will actually get them that day. The next item is D/C. If the patient is being discharged today, filling out discharge forms and discharge prescriptions takes priorityand may, in fact, trump ordering studies on other patients. Patients who are within a day or two of discharge should also be flaggedas a medical student, you will help your intern a lot by filling out discharge paperwork a day or two early. Some patients will have special social work needs prior to discharge, and those should be undertaken at least a couple of days prior to discharge. Note that routine orders are given lower priority than items already described, BUT you can often get them out of the way during rounds if you carry the patient chart near you when you present. As soon as a plan is agreed on, you can write in pertinent orders. This takes care of scut before it even becomes scut. After orders, the next item is Check as in check to make sure PT has started seeing patient, or check on why patient didnt get chest X-ray last night, i.e. troubleshooting. This is followed by calls to services other than consult services, e.g. social work, and then miscellaneous scut. This latter category often includes non-urgent procedures, which are usually done after lunch, and after most other scut is completed. Also, each row has a little checkbox next to the patients name, to mark off when the daily note has been finished. Notes should, in an ideal world, be done by noon. The final column is sign-out. This is not pertinent for MS3s, but MS4s leaving the hospital will be responsible for signing out their patients to the cross-covering intern who is on call that night before going home (see Appendix 5, For the SubI). During the day, key items that need to be brought to the attention of the cross-cover during sign out can be jotted down in the last column. Warning: The main point with organizing scut is to be as fast and efficient and possibledont be too rigid in prioritizing that it slows you down. Be flexible. Scut should be prioritized based on the needs of the patients, and in some cases a patient may be sick enough that you spend all morning on his needs, and defer the rest of the patients scut (except maybe consults) to the afternoon.

About writing orders: In most cases, medical students can write orders, but they must be co-signed by a resident or attending. Much of what youll need to learn about writing orders youll learn from your seniors as you do it, but a few basic pointers are in order. First of all, as noted, its helpful to keep the patients chart handy during bedside rounds, so that someone (who is not presenting) can write down the orders as the team decides on them. Prepared students keep blank copies of order sheets for their patient, so that if they think of orders, they can write them out and have their seniors co-sign them immediately, rather than having to go fetch the chart. (For hospitals with computerized orders, this is obviously unnecessary.) I advise that if you are writing orders for medications, you check it against your pharmacoepia for proper dose and frequency. I give examples of common orders elsewhere in the Guide.