Intern Conference Plan ahead Use Resident Assistants to
Make follow up appointments
On WebCis f/u lists
Fax discharge summaries/patient information
Plan ahead Talk to your patient
How do they pay for meds?
Who is going to pick them out?
How long will the hospital stay be?
Who do they live with at home?
Do they have home health/home PT already in place?
Start your discharge summary Can put in procedures Secondary diagnosis Follow up appointments Pertinent labs Start the hospital course Brief Discharge Summary Most important take home message to patients Diagnosis what you have/had done Medications ***reconciled with home list*** Discharge instructions What to do/what to look out for Follow up appointments Does not have to be exact date Talk with Social Worker Be very nice to these people About Ride They can provide one (ambulance, taxi, bus) Medications They can help pay for them (pharm assistance) Home Health/Home PT They can arrange it Talk with the Nurses Keep them in the loop Nurses will provide Patient education How do I administer lovenox, do accuchecks? They will decipher your discharge summary into patient talk Make sure they understand whats going on with the patient Talk with Home Infusion Talk early and often
They provide home IV therapy
Can arrange IV therapy on Saturday Can arrange acute changes in antibiotic choice IF they know about the patient ahead of time Communicate with PCP Dont have to call Send phone message with dx/tx Not a novel (they can read your d/c summary), just give them a heads up TALK WITH THE PATIENT!!!!!!!!! They will have questions that they want their doctor to answer The more time you put in early in the day answering questions will save you later Key Points Carry over all diagnosis Reconcile medication list Procedures/imaging No need to list every CXR, KUB Pertinent Labs Admission Chem-10, CBC Special labs Hospital Course List by problems Overview of hospitalization Not on HD#1then on HD#2 Express the maximum amount of information in the minimum amount of space Be clear, concise, and coherent The longer it is, the less likely someone is to read it Must do Brief Discharge Summary
To dictate or not to dictate
+/- of dictation
If you start falling behind
They will find you Medical Records keeps a log of physician of record and will track you down for delinquent d/c summaries If you are too delinquent they wont let you work (i.e. wont pay you) till your caught up