intern survival guide
Admit Orders ADC-VAAN-DISMLO-Orders for Admission/Transfers (Separate from your H&P/Transfer Note) Admission: HSM Team (1,2,3), Attending/Resident/Intern/Student with pager numbers! Diagnosis: Primary admission diagnosis and major comorbid conditions (refer to page:…….. Condition: Good, Stable, Fair, Critical Vitals: routine, q _ Hours, notify house officer if:__) Activity: Bed rest, as tolerated, out to chair/toilet, etc. Allergies: NKDA, list them Nursing: dressing changes, elevate bed, spirometry, accuchecks Diet: Regular, Cardiac, ADA, Low sodium IV Fluids: NS @__/Hr, I’s and O’s: Strict/routine, daily weights Studies: Xray, CT, U/S etc (give reason: ex-look for nephrolithiasis) Monitor: Telemetry, continuous pulse oximetry Meds: List em-scheduled and PRN and Prophylaxis (GI/DVT) (Print out Medicine Reconciliation form in ED to Restart/DC Home Meds) Labs: Today’s and AM labs Other: Consults, Chaplain ect. Sign your orders at the bottom(print last name and pager # in BIG numbers!) (AND FINALLY-DON’T FORGET THE CODE STATUS)
Consult/Transfer Note H&P/Transfer Note/Consult Note-(Don’t have to dictate the transfer note, must dictate the H&P/Consult notes within 24 hours of being admitted.) Note-when a patient is transferred to the Unit, a Critical Care consult note must be dictated by the ‘accepting’ CCM team CC: chief complaint (in patient’s words: ex “I can’t breathe well”-not SOB) HPI: put ‘relevant’ past med hx/ROS/and tx prior to admission (If transfer note-for rest of hx may put ‘see dictated H&P’) PMH/PSH: put dates if you can-ex. CAD-sp cath in ‘02/CABG ‘06 MEDS/ALLERGIES: put ‘reaction’ if known SOC/FAM: More the better-minimal is ‘triad’-smoking, booze, and drugs(now and past) ROS: may put ‘remainder of 13 point ROS neg except per HPI’ VITALS: O2 sat @ _, I/O if transfer pt/known PE: give more detail on the organ systems of interest LABS:(important!) at minimum you get labs/CX/imaging on current admission, however-it’s better to have
Consult/Transfer Note H&P/Transfer Note/Consult Note-(Don’t have to dictate the transfer note, must dictate the H&P/Consult notes within 24 hours of being admitted.) Note-when a patient is transferred to the Unit, a Critical Care consult note must be dictated by the ‘accepting’ CCM team CC: chief complaint (in patient’s words: ex “I can’t breathe well”-not SOB) HPI: put ‘relevant’ past med hx/ROS/and tx prior to admission (If transfer note-for rest of hx may put ‘see dictated H&P’) PMH/PSH: put dates if you can-ex. CAD-sp cath in ‘02/CABG ‘06 MEDS/ALLERGIES: put ‘reaction’ if known SOC/FAM: More the better-minimal is ‘triad’-smoking, booze, and drugs(now and past) ROS: may put ‘remainder of 13 point ROS neg except per HPI’ VITALS: O2 sat @ _, I/O if transfer pt/known PE: give more detail on the organ systems of interest LABS:(important!) at minimum you get labs/CX/imaging on current admission, however-it’s better to have