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Jason Haag

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 what’s 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
 Don’t 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#1…then 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 won’t let you work (i.e. won’t
pay you) till your caught up