Resident Readiness General Surgery Read Online Free PDF

than medical school (picture your pager going off every 30 seconds, impatient colleagues, difficult families, crashing patients, etc). To get it right, every time, you need to learn and stick to a system.
B. Make yourself some templates:
   i. Make yourself some skeleton note templates (see examples, Figures 5-1 to 5-4 ) and store in a readily accessible e-mail or computer location.

Figure 5-1. Sample template: admission/consult H+P. Highlighted areas indicate tips and fields to be filled in by the writer.

Figure 5-2. Sample template: SOAP note. Highlighted areas indicate tips and fields to be filled in by the writer.

Figure 5-3. Sample template: procedure note. Highlighted areas indicate tips and fields to be filled in by the writer.

Figure 5-4. Sample template: brief operative note. Highlighted areas indicate tips and fields to be filled in by the writer.
2. Preencounter:
A. Prioritize:
   i. As soon as possible after hearing about a patient, eyeball the patient to determine if she or he is sick or not sick and how much time you have to review the medical records/take care of more urgent issues before seeing him/her.
B. Note preparation:
   i. If the patient is not sick and you have the luxury of time, use your general H+P template to start a preliminary note on the patient, copying and pasting in any pertinent information from the medical records (name, age/sex, medical record no., PMH, medications, allergies, recent labs, and imaging).
   ii. Print and bring with you to confirm any information in your note and fill in the blanks. Note : Do not post information in your note that you, yourself, have not yet confirmed with your patient—this is unethical and dangerous. If you must include an unconfirmed piece of data (ie, a medication list obtained from the electronic medical record of an obtunded patient), then you should clearly note the source and the fact that the data have not been confirmed.
3. During the encounter:
A. Once-over:
   i. The moment you walk into the room, make note of general patient observations and vital signs. Address any abnormalities immediately—for example, hypotension, hypoxia, and somnolence—and if severe, alert your senior. If no acute issues jump out at you, jot down vitals and move on. Include vital signs in every note—they are essential objective data.
B. The CC:
   i. Before mashing on a belly, make absolutely certain you understand what is ailing your patient, that is, the primary issue that drove him/her to the hospital, and the primary focus of everything you do henceforth.
C. Everything else:
   i. Fill in the blanks. Follow your system to avoid missing any key history or exam findings. Formulate a quick impression in your head. Offer to the patient/family/primary team to return and explain impressions/plans once you discuss with your higher-ups.
4. Post encounter:
A. Fill in gaps:
   i. At a computer, pull up your skeleton note, fill in information acquired from the patient, and fill in any gaps by quickly perusing online medical records, calling care providers or pharmacies, and reviewing lab/culture/imaging data.
B. Process the information:
   i. Jot down your impressions. (Sick or not sick? DDx? One or multiple active issues?)
   ii. Jot down any key diagnostic or management moves you would make.
   iii. Jot down any questions for your senior/fellow/attending, lest you forget to ask (eg, are we going to the OR/should I hold tonight’s Coumadin dose?).
   iv. A wise adage: There are interns who write things down, and there are interns who forget.
C. Discuss:
   i. After taking a minute to collect your thoughts, page your senior and present the case in a concise, organized manner. Follow your H+P or abridged SOAP format, depending on the context. Remember to stick to your system, the same way every time. The alternative—presenting data out of order and forgetting key details—generates verbal diarrhea, which confuses your listener,