The Art of Roundsmanship

Handouts created by: Honors Consortium (AOA, Gold Humanism Honors Society, Landacre Honors Society) and Student Council

The following documents are intended to help smooth your transition into new rotations by giving you suggestions for commonly covered topics on rounds for each rotation. Included documents are listed below. These are, of course, only general suggestions created for the most part by students, and you should modify as needed for either your patients or your teams needs. 1) Medicine SOAP note meant to be filled in on rounds, with helpful mnemonics following

2) Surgery SOAP note similar to medicine soap, with surgery mnemonics

3) OB/Gyn SOAP notes as well as templates for other helpful notes, and menemonics following

4) Neurology SOAP note template and helpful neurology information

5) Psychiatry scut sheet helpful for keeping track of history and has a place to record daily updates from medfools.com

6) Antibiotics reference chart this is a modified version of the handout you will get during IM, but it is helpful for all rotations, so we thought you might want it now.

7) EResults quick reference abbreviated version of the handout in your GHHS Guide to Clinical Clerkships to keep in your coat pocketDate

Time:

MS3 Progress Note (medicine)

S:

Interval history?

Pain?

Appetite?

NOW THINK: what is happening with my patient? Anything special I need to think about/look for on exam? Anything I dont understand about what is happening with them?

O: VS: Tm Tc P R BP Sat on

I/O: Gen:

HEENT:

Lungs:

C/V:

Abd: Extremities:

Neuro:Antibiotics? Day of Pain meds?

DVT prophylaxis?

GI prophylaxis?

Diet:

Fluids? Rate?

Labs:

CulturesImaging

A/P

Hypercalcemia Etiologies - CHIMPANZEESC - Calcium overdose (dont usually mention this one)

H - Hyperparathyroidism, Hyperthyroidism, Hypothyroidism, familial Hypercalcemic hypocalciuria

I - Immobility

M - Multiple myeloma

P Pagets disease

A Addisons disease

N Neoplasms:

- metastasis to bones and

- hypercalcemia of malignancy (a paraneoplastic syndrome)

Z Zollinger-Ellison syndrome

E Excess vitamin A

E Excess vitamin D

S Sarcoidosis

Indications for Acute Hemodialysis - AEIOUA Acidosis (unable to be managed medically)

E Electrolytes (typically hyperkalemia, unable to be managed medically)

I Intoxication (methanol, ethylene glycol, lithium)

O Overload (fluid overload unresponsive to diuretics)

U Uremia (symptomatic)

Causes of delirium MOVE, STUPID

Metabolic

Oxygen

Vascular

Endocrine/Electrolyte

Seizures

Tumor/Trauma/Temperature

Uremia

Psychogenic

Infection/Intoxication

Drugs/Degenerative disease

Causes of metabolic acidosis with an anion gap MUD PILES

M methanolU uremia

D diabetic ketoacidosis

P para-aldehyde

I Isoniazid, iron, inborn errors in metabolism

L lactic acidosis

E ethanol, ethylene glycol

S salicylates

Treatment of Acute MI MONA

M - morphineO - oxygenN - nitratesA aspirinDate

Time:

MS3 Progress Note (surgery)

S:

Interval history?

Pain?

Bowel movement?Nausea/vomiting?Flatus?

Appetite?NOW THINK: what is happening with my patient? Anything special I need to think about? Anything I dont understand about what is happening with them?

O: VS: Tm Tc P R BP Sat on

I/O:

Drains?

Gen: Sick vs well appearing?

Lungs:

C/V:

Abd: Distention? BS? Soft? Tenderness? Guarding? Rebound?

Wound: where? Clean? Dry? Intact? Erythema? Drainage?

Extremities: Tenderness? Swelling? Warm?

Antibiotics? Day of

Pain meds?

DVT prophylaxis? GI prophylaxis?

Diet:

Fluids Rate?

Labs:

Cultures

Imaging

A/P

Etiologies of Postop Fever

Causes of Panceatitis

The 5 Ws

I GET SMASHEDWind (atelectasis, pneumonia)

Idiopathic

Water: UTI

Wound: infection

Gallstones

Walking: DVT/PE

Ethanol

Wonder drugs: drug fever

Trauma

Fistulas: conditions preventing closure

Scorpion bites

HIS FRIEND:

Mumps (viruses)High output (>500mL/day)

InfectionIntestinal destruction

AutoimmuneShort segment ( pt name > Note the new set of tabs that come up to the left [Patient Info, Clinical Summary, Medications, etc, etc.]. This method is best for looking up data for patients who are not currently admitted/active in the hospital (i.e. they are incoming so you can get ready for them to come in).

Accessing Patients on Your Services Census: CapiWeb/Results >Service Census > click on your services tab (Ge2, Me1, etc)> click on the blue pt name/hyperlink for your desired patient from the census that comes up> Note the new set of tabs that come up to the left [Patient Info, Rounds Report, Results, etc.]. On the first day, find out what your Service Census code is!

Setting your default Census (so that every time you hit the Service Census tab it will automatically bring up your services census.

CapiWeb/Results> Change Default Census> Select Service button > Hit your Services hyperlink and then the Enter button.

Finding Patients on Your Services Consult Census/Finding Your Services Consult Census: CapiWeb/Results >Clinician Census >Physician Consult>Type the first letters of your service into the dialogue box (Surg, ENT, etc)> click on your services hyperlink> click on the blue pt name/hyperlink for your desired patient from the census that comes up> Getting Prepped for Rounds:

Printing out your Services Census: includes recent labs, meds and handoff note included for each patient (great to have on rounds)

CapiWeb/Results>Print for Multi Pts>Service Census>Click on the hyperlink for your service>select all (button at bottom)>Print for Selected Patients>MD Rounds (Notes/ To Do/ PMH/ Labs): if you want one/page this is an option above the type of note you want printed.

People like to add their daily info on these handouts to be ready to present during rounds.

Every morning you can just go to Rounds Report which will bring any notes, studies, labs, imaging that was done in the past 24 hrs.

H&Ps:

Results > Encounters > History and Physical: use this to see what has already happened with your patient. Sometimes the H&P is in the Chart handwritten under H&P or Progress Notes.

To look at notes from the ED: Result > Encounters > Emergency so you can see what was done with the patient before they came in.

Consults:

Results > Encounters > Consultations OR look in the FRONT of the chart on yellow paper!

Labs:

To get a full view go to Results > Last 5 occurrences, check all the tabs since they are listed under different things: hematology, body fluids, chemistry etc

Micro:

Results > Micro (back 90days) OR Micro(back 2.5 yrs). Make sure to check if it is Pending or the final read. Look at sensitivities.

Imaging:

Results > Radiology > occasionally find reports here (better to use RadWeb).

Use RADWEB program to look at imaging

Procedures: (Cath reports, EEG reports, EGD reports, Colonoscopy reports

Results > Procedures

if you want to see past reports that arent showing up click on the check box and then click view all.

Surgical/Pathology:

Results > Surg/Path

Current Orders:

Results>Display Current Orders > see all the medications they are on currently. Can use this to see if the orders discussed on rounds were followed up on and put in.

You might also need to check Orders > View orders > then select pharmacy/lab etc to see if an order was placed > hit enter

Look at past discharge summaries if patients dont know their medications: Results > Encounters > Discharge summaries

Under Documentation >Charted Med or MAR > click past # days you want > click display charted medications > enter: this shows you what medications the patient was actually administered. Allows you to see if they are refusing medications or if one-time orders were given. Also the place to see their insulin coverage if they are on carb coverage

In the CHART: Charts are in boxes outside the patient rooms the code is 2+4, then 3, turn, Or in the James at the nurses station.

Vitals:

- on a dedicated clipboard or in the chart (harder to find) under the Nurse Flowsheets tab.

- report ranges of vitals over the past 24 hrs. Make sure to divide up I/Os by type of Output

- look at the nurses notes on the back of the vitals sheet.

- All the ICUs, Ross heart, L&D: Use Essentris (another program with another password).

Consults: in the front on yellow sheets of paper

Progress notes: see follow up consult notes, PT/OT/Speech notes, progress notes for all services except medicine.

Paperwork from Outside hospitals: usually in the back of the chart or at the clerks desk.

Other Helpful Tips:

Writing Handoff Notes

Documentation>Notes> Enter/Revise Handoff Note (just write the pts one-liner and the major 3-5 parts of your management plan)

Writing Hospital Courses

Documentation>Arrival Meds/DI> Enter / Modify (under Discharge Instructions Heading) > Categories (at bottom of screen) > Check Physician, Procedure, Hosp Course box and hit Enter button at bottom of screen

You MUST put in a dictating physician (type in the name of your resident, then search) or your hospital course will NOT save> then hit enterwill take you to procedures

Procedures: type in pertinent procedures> enter;

Hospital Course: Summary is one liner: Course gives info about what you did for the patient.

Hit SAVE, NOT FINALIZE

Might be helpful to do it in your email and then enter daily b/c the formatting gets messed up.

Looking up that days OR schedule

CapiWeb/Results > OR Schedule-Campus or UHE > Choose the proper date and sort by Surgeon, Room Number, etc. Also be sure to select UH, James, or Ross Ors when looking for your case based on where its being performed that day (tabs at top of screen).