By Katie Gabriel, Carolyn and Mike Stalvey
This handout is meant to be a helpful guide to each rotation. There is a
lot of overlap in what is expected of you in the different rotations
especially in regards to your duties on in-patient rotations.
Preround: This means checking on your patients before rounds.
You should find out what everything that has happened since you last saw
them. This includes looking through the chart and visiting with the
patient. Look in the "Orders" section of the chart to see if
there are new orders. Also check to see if anyone has written a note in
the "Progress Notes" since your last note. Sometimes if
something happened during the night the person on crosscover will write
a note explaining what happened. Other times a consult team might have
written a note in the progress note section. Also check the
"Consults" section to see if they wrote their note there.
Check to see if any labs have come back on the patient. Remember to go
back and check blood/wound culture results in the computer - it will be
under the day it was done, not the day it comes back. This works the
same with pathology. If any radiology studies were done, check the
computer to see the results. At the VA you sometimes have to call and
listen to the dictation (your Third Year handbook tells you how to check
the dictated radiology reports.)
Go to the patient's room. Look at the vitals chart and write them
down to present during rounds. Make sure you look to see what their Tm
(Max temp) was and write down the time if they spiked a fever. Use your
common sense too - if they are having problems with their blood pressure
make sure you notice what they have been over the last 24 hours. Look at
I & O's (intake by mouth and IV; output by urine and any drains),
weight, bowel movements, emesis (vomiting), … These should all be
documented by the nurses on the vital chart.
Talk to the patient (and wake them if sleeping) and see how they are
doing. Ask questions pertinent to their reason for hospitalization. For
example, if they had a heart attack, ask if they have had any chest
pain. Do a quick physical exam on the patient including a lung, heart,
abdominal and extremity exam. Again use your common sense and exam
anything pertinent to their condition.
Some services will expect you to write your progress note prior to
rounds. So make sure you leave enough time!
Rounds: This is when the team discusses the condition and the
plan on all the patients. Usually the team will walk around and visit
each patient although on some services rounds are done sitting down as a
team. It is usually the medical student who "presents" on
rounds. This means telling the team your patients' condition. The key to
presenting is to be organized and systematic. Presenting on rounds can
be nerve-wracking so try to have your information organized. Try not to
read from the papers in front of you - you want to try to look at the
team. It will make you look more confident and prepared. In general you
will do two types of presentations: a full H & P (history and
physical) and the SOAP method.
H & P - This is generally done for new patients. Every
attending has different expectations of how this should be done. It
would be best to ask them at the beginning how they expect you to
present. Do you start with "Chief compliant of chest pain for 3
days" or with an opening statement of "This is a 56 y.o. (year
old) with a history of hypertension who presents with a three day h/o
(history of) chest pain". If you don't ask what they want, expect
to be given feedback --- in the end you might wind up doing it the exact
opposite of how your last attending wanted you to present. The general
order is similar to the write-ups you did for Physical Diagnosis (CC,
HPI, PMH, PSH, SH, FH, ROS, PE, Labs, Studies, Assessment, Plan). Also
there is variability in how much to include. In general, if you are told
to present only the "pertinent positives and negatives", skip
the fact that they have three kids in Alaska if that has nothing to do
with their present condition.
SOAP - This is the general format for day-to-day presenting.
To begin, especially on surgical services, state what hospital day or
post-Op day it is (for example: Mr. Smith is post-op day number 2 for an
appendectomy). Then begin with:
S = Subjective - what the patient tells you. This includes
nausea, vomiting, chest pain, appetite, pain, and other pertinent
symptoms.
O = Objective - vital signs, physical exam,
A = Assessment - how you feel they are doing; what are their
diagnoses
P = Plan. Sometimes A/P can be presented together by problem
(for example: "Hypertension - BP is well controlled. Will
continue on Vasotec and Lasix.") Or you can do A/P together by
system ("Pulmonary - Lungs sound improved and oxygen saturations
have improved. Will continue on the Albuterol nebulizers bid")
Labs and Radiology studies are usually presented between O and A.
THE MOST IMPORTANT NOTE ABOUT PRESENTING: Make sure you
present the information in the correct order. Don't say "the
patient reports he has been coughing up green sputum (subjective) but
his lungs sound fine to me (objective) but he has been feeling
nauseated and vomited twice (subjective)". Try to stay calm and
present in the correct order.
Progress Notes: These are the day to day notes that are
written in the chart and usually written by the medical students.
Progress notes are an important method of communication between the
primary team and anybody who is involved in the patient's care. This
includes consults, nursing, physical therapy (PT) and occupational
therapy (OT). Generally they are done in the SOAP method. Depending on
the rotation you may need to write the notes before rounds.
A general example of a SOAP note:
Date
MS3 PN (medical student, year 3, progress note)
Time
HD #2 or POD (post-op day) # 2 s/p (status post) appendectomy
S: Pt c/o (complains of) three episodes of chest pain associated with
N/V (nausea and vomiting).
O: VS (vital signs): BP P R Tm
Tc O2 sat
Chest: CTA B (clear to auscultation bilaterally)
CV: RRR, Nl S1 and S2,
o m/r/g (regular rate and rhythm, normal S1 and S2, no murmurs,
rubs or gallops)
Abd: + BS, NT/ND, o HSM, soft
(positive bowel sounds, non-tender, non-distended, no
hepatosplenomegaly)
Ext: o C/C/E (no cyanosis, clubbing, edema)
A/P: HD #2 (Hospital Day) or POD (Post Op Day) #2 s/p _______
1. HTN (hypertension): well controlled (or not) on HCTZ 25 mg Day 2
2. Pneumonia: Improving on Zithromax Day 2/5 (This is Day 2 of a 5 day
course)
SIGN YOUR NAME MS3 (sign at the bottom of every page
****** Tip: At first it may seem nerve-wracking to think up on your
own what the plan should be on a patient. But go out on a limb when
presenting and writing notes - it shows that you are thinking. For
example, if the patients blood pressure is elevated try saying/writing
"consider increasing the Metoprolol to 50 mg bid". The key
word in the progress notes is "consider" because you don't
want to write something that is wrong and have it in the chart as the
team's plan for the patient.******
What to keep in your coat pockets: Always have a stethoscope.
The Pharmacopoeia and Sanford's Guide to Antimicrobials are good books
that fit easily. The Third Year handbook is very helpful - sit down and
look through it so you know what information is in it. Some people kept
little black three-ring binders or use their Palms that they would take
notes in or write down little "pearls".
Organization - This is the key to looking prepared and keeping
on top of things… Develop a method to keep all the information on your
patients organized. Whether you use a simple index card or a more
complicated method, the bottom line is to have all the information
organized and accessible to you. You want to be able to look and see
what medications the patient is taking now (and preferably what they
were taking at home), what their lab values have been, what radiology
studies have shown and any other work up being done. Some also like to
have room on their cards or patient sheets for a limited H and P.
Who can I ask questions about what to do? Usually start from the
bottom and work your way up. Ask the fourth year first. If they don't
know then try the intern, then the resident.
Medicine
Preround/Round/ Progress Notes: See the information given
above. Often notes can be done after rounds especially if you are not
sure what the plan will be.
Tips:
-
Try to write any orders for the patient.
They have to be co-signed by an intern or resident anyway. But try
to be assertive and do this - it is the best way to learn. Writing
orders challenges you to think about the patient's problem and what
the plan is for his/her treatment.
-
Again, it shows initiative and insight
if, when presenting and when writing progress notes, you offer a
plan. Often medical students get through the subjective and
objective part of presenting and then stop. So if the patient has
been having elevated blood pressures, suggest increasing their dose
(And look up in your Pharmacopoeia what the dose should be!). When
writing a progress note write "Consider increasing the dose of….."
This is the best way to go out on a limb without committing to a
plan if you are not sure.
-
Read at night about your patients'
disease. This is the best way to learn and you will probably be
asked questions on rounds about it so be ready!
-
At the VA, the fourth year student does
cross-cover at night. So ask to follow them around since it is
another good way to learn. Also ask the 4th year how to do ECGs,
blood cultures and blood draws because you will be doing some
yourself especially at the VA.
Surgery
At the first day they give you a handout that explains a lot of what
is expected of you: your ward responsibilities, how to write surgical
notes, and other little tid-bits.
Preround:
S: Appropriate to their problem. If post-op (especially
abdominal surgery), ask about flatus (passing gas - signifies GI
movement returning), bowel movements, pain, N/V (nausea, vomiting),
appetite, are they tolerating what they are eating if anything. Have
they been using their incentive spirometers (IS), are they getting OOB
(out of bed)
O: VS - BP, P, R, Tm and TC, and I
& O's (including OUP (urine output)/hour, output from drains and
Foley urine catheters). A quick physical exam, look at the incision
and any drains to see if they look erythematous or have exudate.
Note: Peds surgery will require the I & O to be calculated as
is done in Pediatrics so read that section.
Labs/Radiology/Surgical Pathology: check to see what results
are back.
Rounds: Be brief!!! They usually don't take the time to stand
there for a long presentation. Present in SOAP fashion and start by
saying Post Op Day # _ s/p (status post) whatever procedure. When you
get to Objective, just give pertinent - if they had abd surgery you can
mention if you heard bowel sounds and how the incision looked. You don't
need to mention that their lungs were clear or they had good heart
sounds if that hasn't been a problem in the past. Make sure you know
what antibiotics they are on and for how many days they have been on
them.
On most services you will change the bandages on rounds so once you
get a feel for how things work, try to have what is needed ready for the
residents.
Progress Notes: Usually should be done before rounds but if
there are too many sometimes you can finish them between surgery
cases.
Tips:
-
Ideally prepare the night before for the
next days surgical cases by learning the appropriate anatomy
(structures, vascular supply and drainage,..), how the procedure is
performed, complications, …
-
"Scrubbing in":
-
If you are not sure if you should
scrub in for a case, ask the resident or attending "CAN I
scrub in", not should I. This way it looks like you want to
even if you don't! Remember, fortunately or unfortunately, this
is subjective grading and you want to look enthusiastic. Tell
the nurses that it is your first time and make sure they get out
a pair of gloves and gown for you. If you tell them it is your
first day, you are less likely to do something wrong and
contaminate something.
-
The general rule: Scrub 30 sec
longer than those above you.
-
In the OR: Your role in surgery is
generally to retract and cut sutures. So when the surgeon gets
sutures and is tying the knot, ask the nurse for suture scissors.
Hold the scissors with your thumb and ring finger and ask how long
to cut the suture. You will usually do it too long or too short -
there is rarely an in-between!
-
In general, all students should be
in the OR even if you are not scrubbed in.
-
Lectures are supposed to come before
surgery and clinic
-
Wear regular clothes on clinic days
and for oral exam
-
Ask whether you should write an
"Op Note" - this is the note written about what
happened in surgery and a good example is in the Third Year
Handbook
In Your Pocket: Stethoscope, Pharmacopoeia, Sanford, Third
year handbook, Scissors to cut bandaged on rounds (can get from Clean
Holding - ask the fourth year or intern), Pen light
Psychiatry
Prerounds/Rounds: Depends on team if you should go see
patients before rounds. Ask how they slept, how is their mood. Physical
exam only if current problem although you do a complete H&P on
admission.
Presenting and Progress Notes: SOAP format. For Objective,
though, you write in the MSE (Mental Status Exam) format. One of the
first lectures in the rotation is about the MSE. For Assessment, the
format is by Axis (look in DSM - IV or ask the residents). Notes can
usually be written after rounds.
Tips:
In Your Pocket: Stethoscope, Pharmacopoeia, Sanford, Third
year handbook, House Officers Guide for Psychiatry or DSM IV (you will
be given a copy the first day), Copy of MSE to help you write notes.
OB/GYN
They give really good handouts at orientation about what is expected.
Make sure you read them carefully.
Preround:
S: Appropriate to their problem. If post-op or PP (post-partum),
ask about flatus (passing gas - signifies GI movement returning),
bowel movements, pain, N/V (nausea, vomiting), appetite, are they
tolerating what they are eating, vaginal bleeding and amount, are they
getting OOB (out of bed)
O: VS - BP, P, R, Tm and TC, and I & O's (including OUP
(urine output)/hour, output from drains and Foley urine catheters). A
quick physical exam. On Gyn and after C-sections, look at the
incision. Also on Gyn, check if they have any drains from their
abdomen to see if they look erythematous or have exudate.
Labs/Radiology/Surgical Pathology: check to see what results are
back.
Rounds: Usually the SOAP format. Start with PPD (post-partum
day) or POD (post-op day) and what they had done. On Gyn and sometimes
on OB after CS (C-sections), you will change the bandages on rounds so
once you get a feel for how things work, try to have what is needed
ready for the residents.
Progress Notes: Have notes done before rounds and use the SOAP
method
Tips:
-
Keep the pregnancy wheel with you at all
times (they give you one)
-
GYN: Your role in surgery is generally
to retract and cut sutures. So when the surgeon gets sutures and is
tying the knot, ask the nurse for suture scissors. Hold the scissors
with your thumb and ring finger and ask how long to cut the suture.
You will usually do it too long or too short - there is rarely an
in-between!
-
All students should be in the OR if not
assigned elsewhere. One person is generally scrubbed in but usually
the others have to be in the OR as well.
-
You should write an "Op Note"
- this is the note written about what happened in surgery and a good
example is in the Third Year Handbook
-
OB: Make sure the resident knows where
you are at all times if you are on call. Help out as much as
possible with writing notes. They do a lot of paper work including
admission notes, delivery notes, … and they want the medical
student to do as much as possible.- Remember that you are being
grades subjectively so give it your all.
-
The more you ask and try to do, the more
you will be able to do. Be assertive!
In Your Pocket: Stethoscope, Pharmacopoeia, Sanford, Third
year handbook, Pregnancy wheel and reflex hammer (unless you learn how
to use your stethoscope to check reflexes)
Family Practice
Different clinics work differently so ask on Day 1, what is expected
and how they like the notes to be written. Look in the charts to see the
format of how the attending writes his/her notes. You may want to shadow
for the first few patients to get a feel for how things work.
In Your Pocket: Stethoscope, Pharmacopoeia, Sanford, Third
year handbook, Pen light, reflex hammer (unless you learn how to use
your stethoscope to check reflexes)
Anesthesia
Tips:
-
Be assertive and try to do intubations -
it is your only chance third year. If you are not learning anything
in one OR, go to another room - no one should be offended.
-
You will have to fill out a sheet about
one patient that includes some pre-op and operative information.
Keep that sheet in your pocket so you can fill it out on a shorter
case. You don't want to have forgotten about it and then have to sit
through a 15 hours surgery to get it done the last day!
-
This is the best time to get a lot of
studying done for your medicine test so use this time as much as
possible!
Pediatrics
Preround: Some general idea as described at the beginning.
Some things special to Peds:
S - Ask parent, appetite, energy level, playfulness vs. irritable,
stool (what did it look like!), sleep
O - I & O (ins and outs) are very important. Need to calculate
every day's values as follows: **(see below)
In: cc/kg/day. Also depending on what they are eating you might
figure out
kcal/kg/day
Out: cc/kg/hour. Should be >1. Bowel movements are not
usually counted in this,
so find out how many and how much
Weight - may need to do a growth chart yourself
A/P: Done by systems
FEN (Fluid, Electrolytes, Nutrition), Pulmonary, Cardiac, ID
(infectious disease),
Newborn nursery -
** The calculations for Ins and Outs are explained the first few
days on the rotation in a lecture.
Rounds/Progress Notes: Similar as described in the general
section although be sure to mention those areas important to Pediatrics
(see "Preround)
Tips:
-
Study as much as possible during the
outpatient weeks
-
Try to write any orders for the patient.
They have to be co-signed by an intern or resident anyway. But try
to be assertive and do this - it is the best way to learn. Writing
orders challenges you to think about the patient's problem and what
the plan is for his/her treatment.
-
Again, it shows initiative and insight
if, when presenting and when writing progress notes, you offer a
plan. Often medical students get through the subjective and
objective part of presenting and then stop. So if the patient has
been having elevated blood pressures, suggest increasing their dose
(And look up in your Pharmacopoeia what the dose should be!). When
writing a progress note write "Consider increasing the dose of….."
This is the best way to go out on a limb without committing to a
plan if you are not sure.
