Intern Survival Series Lecture #2 Introduction to Medicine Part 2 - PowerPoint PPT Presentation

Intern Survival Series Lecture #2 Introduction to Medicine Part 2 Shaping the Future of Healthcare | www.thewrightcenter.org

Objectives • After participating in this lecture, you should be able to: – Identify the roles of the Service Team – Complete a comprehensive H&P exam – Have an understanding of the flow of admitting orders, and be able to write as needed with appropriate supervision – Identify and complete all parts of a SOAP note – Identify and complete an appropriate discharge summary Shaping the Future of Healthcare | www.thewrightcenter.org

A Brief Note • This lecture series is not meant to be all inclusive or totally comprehensive to all of medicine • It is not meant to supersede clinical judgment • It is not meant to replace daily reading or bedside teaching • It is meant to act as a starting point for which to grow from as new primary care physicians • It is a tool to help you survive the your new job Shaping the Future of Healthcare | www.thewrightcenter.org

Hospital Admission • Orders are now done almost exclusively through EMR. – EPIC  GCMC – Sorian  Regional and Moses Taylor Hospitals – VA CPS  VAMC WB Shaping the Future of Healthcare | www.thewrightcenter.org

Admitting Orders • ADCA VAN DIMLS • mnemonic device for recalling hospital admission orders. • The letters stand for – A dmission – N ursing Communication – D iagnosis – D iet – C ondition – I V Fluids – A llergies – M edications – V itals – L abs – A ctivity – S pecial (consults, imaging, etc) Shaping the Future of Healthcare | www.thewrightcenter.org

Sample Admission Orders • Observation: Remote Tele • IV: Heplock • Dx: New onset Afib • M: Metoprolol Tartrate 25mg PO BID • Condition: Guarded – Rivaroxaban 20mg PO HS • NKDA • Labs: – Cardiac enzymes x3, 8 hrs apart • Vitals q shift – RFP w/ Mg in am • Activity: OOB to chair • Special: • Nursing: Call for HR>120 – EKG in am • Diet: Heart Health 2000cal – CXR- PA/Lateral views diet – 2D echo, reason: abnormal EKG Shaping the Future of Healthcare | www.thewrightcenter.org

Progress Notes • Daily notes – descriptive document that chronicles a patient’s hospital course – Brief, not meant to be a repeated H&P – Highlight important data – Express clear clinical impression Shaping the Future of Healthcare | www.thewrightcenter.org

Progress Notes • Basic Format is a S.O.A.P. note – Subjective Information – Objective Data – Assessment of Clinical Picture – Plan of Care • Data Collected/Reported – not meant to be a recapitulation of the H&P – Old events described in earlier notes should not be repeated Shaping the Future of Healthcare | www.thewrightcenter.org

Sample Soap Note S: 65 yo male hospital day #2, patient reports one episode of acute onset, 2-3 second chest pain • while at rest, associated with movement, remitting spontaneously without reoccurrence, similar to presenting symptoms. No other complaints or problems, tolerating diet, ambulating on own w/o complaints or problems. O: • Vitals: 97.8, 55, 18, 120/86, 98%RA, accucheck 96 – G: NAD – CV: RRR, +s1/s2, no m/c/g/r – R: CTA – A: +BS, s/nt/nd, no pain with deep palpation – Ex: -edema, clubbing or cyanosis, +strong peripheral pulses B/L – N: no focal deficits, A&Ox3 – Labs: Trop 0.00 x3, Sodium 140, K+ 4, Cl- 106, CO2 26, BUN 20, Cr 1, Glucose 100 – EKG: NSR @ 76bpm, normal axis, RsR’ in V1 – A/P • 1)Chest Pain: Acute Coronary Syndrome vs GERD vs costochondritis – 2)Hypertension: Controlled with Lisinopril – 3)DM II: stable with metformin – 4)DVT prophylaxis: enoxaparin – Shaping the Future of Healthcare | www.thewrightcenter.org

Common Daily Orders Electrolyte Replacement Potassium • – (goal 4-4.5)-do not replete if pt is on HD – Example Order – KDUR 20meq PO Q.I.D. x 1 day (MAKE SURE YOU PUT AN END TIME ON ORDER) – 10mEq of K raises serum K by 0.1mmol. • For mild renal failure, cut the dose in half. • For severe renal failure (CrCl<30) ask senior resident for help. Administration Consideration • – PO tabs are huge – Liquid tastes gross, fast-acting – IV can be painful through a peripheral line. Go Slow • KCL 20mEq in 100ml sterile H20 IV, run at rate of 10mEq/hr – Ideally run through a Central line – Can be added to maintenance IVF Shaping the Future of Healthcare | www.thewrightcenter.org

Common Daily Orders Electrolyte Replacement • Magnesium (goal>2)-do not replete in HD – 1 g of Mg will raise Mg level by 0.1. – PO: Mag Oxide. • Causes diarrhea, consider not replacing if K+ is WNL • Mag oxide 400mg PO BID (x4 doses if Mg 1.5-1.7, x6 if <1.4) – IV: Mag Sulfate • 8mEq if Mg 1.6-1.9 In 100 ml D5W • 16mEq if 1.3-1.5 • 32mEq if 1-1.2 In 250ml D5W Shaping the Future of Healthcare | www.thewrightcenter.org

Common Daily Orders Electrolyte Replacement • Phosphate (goal 3-4.5, usually replace if <2.5) • Replacement options – Neutraphos 1 packet PO TID x 1 day – Kphos 1-2 Tabs PO QID x 1 day – Kphos 15mmol in 100ml NS IV, infuse over 6 hrs, x 2 doses Shaping the Future of Healthcare | www.thewrightcenter.org

Common Daily Orders Electrolyte Replacement Calcium (goal 8.5-10) –don’t replete in HD unless dangerously low and nephrologist aware • Remember to correct for albumin. • – Corr. Calcium=Ca + 0.8 x(4-Alb) Be very cautious when giving Calcium- Can precipitate MI, HypoTN, arrythmia etc • Indicated when decreased level causing increased QTC, seizure, arrhythmia • PO: • – Tums – Calcium Carbonate 500mg PO BID/QID for 1-2 grams total IV: • – Calcium Gluconate 1-2g IV runs (1st choice for peripheral IV) – Calcium Chloride 1-2g IV runs (through central IV’s only ~4-5x as potent!) Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Discharge Summary • A vital tool for transferring information between the hospitalist and primary care physician • Extremely important for continuity of care • Discharge planning should start at the time of admission Shaping the Future of Healthcare | www.thewrightcenter.org

Discharge Summary • The Joint Commission mandates that discharge summaries contain certain components: – reason for hospitalization – significant findings – procedures – treatment provided – patient’s discharge condition – patient and family instructions – attending physician’s signature Shaping the Future of Healthcare | www.thewrightcenter.org

Discharge Summary • Research suggests summaries contain insufficient or unnecessary information and fail to reach the primary care physician in time for the patient’s follow-up visit, if they arrive at all. • Delay can cause – patient harm/frustration – repeated and unnecessary tests – medical error Shaping the Future of Healthcare | www.thewrightcenter.org

Discharge Summary • A structured, standard discharge summary form ensures that all the important information is included • Allows the receiving physician to more quickly identify how to respond to the patient’s hospitalization • Should be completed within 24 hours of discharge Shaping the Future of Healthcare | www.thewrightcenter.org

Discharge Summary • Standard Format in a Local Hospital System 10. Disposition 1.Patient Name • • a. Medications • 2.Medical Record Number • b. Follow up • 3.Date Admitted • c. Special Instructions • 4.Date Discharged d. Activity • • e. Diet • 5.Encounter Number • f. Condition • 6.Diagnosis • 11.History • Principle 12. Physical Exam – • Secondary 13.Hospital Course – • 14.Laboratory 7.Operations/Procedures • • 15. Consults • 8. Complications • 16. Referring Physician • 9. Allergies • Shaping the Future of Healthcare | www.thewrightcenter.org

Important Notes for DC • As residents we often take patients who do not have a PCP • These patients are frequently asked to follow up at a WCGME clinic • If that is the case YOU MUST – call the clinic – make an appointment for the patient – Relay any FU instructions/tests patient is scheduled for to the proper care coordinator Shaping the Future of Healthcare | www.thewrightcenter.org

Important Notes for DC • Patients on COUMADIN or INSULIN – NEED to have inr, coumadin dose or insulin regiment communicated verbally to the clinic via telephone – Very important for patient safety Shaping the Future of Healthcare | www.thewrightcenter.org

Office Phone Numbers • Scranton Clinic – (570) 941-0630 • MVP – (570) 383-9934 • Clarke’s Summit – (570) 585-1300 • Student Health – (570) 955-1474 Shaping the Future of Healthcare | www.thewrightcenter.org

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