Resident Readiness General Surgery Read Online Free PDF Page B

guarantees you getting interrupted and flustered, and hinders patient care.
   ii. Write down the plan dictated by your senior, and remember to amend both your note and your to-do list with any additional impressions and plans dictated by your attending.
D. Execute:
   i. Carry out the plan.
   ii. By now, your note should already be written. Print, sign, and place in the chart as promptly as possible, that is, in real time for daily progress notes and postoperative checks, and within several hours to half a day for admissions/consults. Note : Patient care always comes first. In the worse case scenario, when you are between bedsides of unstable patients and unable to write a complete admission or consult note, jot a “brief note” in the chart (date/time, 1-liner about the patient, and brief plan) and remember to write the full note as soon as time allows.
    ADMISSION NOTE SPECIFICS
    Purpose: To organize myriad data into a comprehensive and concise H+P that highlights your patient’s primary problem and provides all necessary baseline data and proposed plans. This note should help focus and guide your team and consultants.
    Essentials:
1. As mentioned before, make sure you understand your patient’s chief complaint.
2. Confirm and document all medications, doses, and allergies. While tedious, this is helpful for consultants and essential to writing appropriate admission orders.
3. Tailor the exam to the chief complaint, but remember to check and document baseline vitals, mental status, cardiopulmonary exam, and pulses, asany of these things can deteriorate perioperatively or over the course of an acute illness and are difficult to monitor if you have no knowledge of the patient’s baseline.
4. Guided by insight from your senior/fellow/attending, write a clear assessment of the patient’s condition and cause of chief complaint, and lay out a comprehensive plan by organ system or issue (see Figure 5-1 ). Note : Do not document anything that you are unsure about and have not clarified with your senior. Assumptions lead to confusion and, in the worse case, patient harm.
    CONSULT NOTE SPECIFICS
    Purpose: To identify and address the specific reason for consultation with pertinent data, impressions, and management recommendations. Stay focused.
    Essentials:
1. Absolutely speak with the primary team to clarify their exact question/reason for consultation. If the intern is unclear, go up the chain. If you are unclear, you waste a lot of people’s time. Document the reason for consultation (in addition to or in lieu of CC) in your note.
2. Document the date/time of consult.
3. Clarify and document from whom and to whom (ie, from/to which service and attending) the consult is being requested.
4. Focus your history and exam on the reason for consultation. You are not the patient’s primary doctor. Caveat : If you encounter an unstable patient, be a doctor, alert the primary team immediately, and help stabilize the patient as appropriate.
5. Communicate a very specific assessment and plan to the primary team, in person and in writing. Include:
A. Your team’s impression of the problem/question being asked
B. Specific management recommendations, including what exam findings/vital signs/labs/imaging to monitor and how often, diet/NPO status, IV fluids, medications, surgery, and other procedures
C. Threshold to call, and whom to call, with any questions or concerns
6. Remember to document with whom you discussed the plan on both your and the primary team’s note.
    DAILY PROGRESS NOTE SPECIFICS
    Purpose: To provide a concise and thoughtful daily update of inpatient progress and anticipated disposition. Remember : These notes are a major avenue of communication with attendings and consults and are useless if late, illegible, inaccurate, or lacking in explanations for any new plans.
    Essentials:
1. Pare down the H+P to a SOAP approach/note in real time (see Figure 5-2 ).
2. Develop and stick to a system that enables you to