Patient Care Responsibilities

Patients

1. During your rotation on Medicine, you will have close daily contact with patients and their families. You will be learning medical facts and developing problem solving skills as well as developing equally important interpersonal skills in terms of the physician–patient and physician–family relationship. Although it may sound trite, please remember that patients are sick and their families, worried. Think about what you're going to say before you say it.

2. Always discuss up-coming issues regarding diagnosis, prognosis, or management with your housestaff and attending before talking with patients and family.

3. The central focus of your experience on Medicine will be the patient.

4. You will be assigned two on-service patients at the onset of each 4-week portion of the rotation.

5. You should admit and follow of 2 to 3 new patients per week throughout the rotation and maintain a service of up to five patients at any one time.

For Each Patient You Admit

1. Perform a complete history and physical examination on the day of admission.

2. Formulate a complete problem list.

3. Review the patient’s X-rays with housestaff and/or a radiologist.

4. Review the patient’s EKG with housestaff.

5. Look at the peripheral smear on all patients with anemia. Review with either the housestaff, Hematology Fellow or attending physician.

6. Know the results of all your patients’ data.

Procedure Documentation

Please remember that you must perform procedures on your patients under supervision of someone who knows how to do the procedure before you do any procedure unsupervised. You should ask a houseofficer, nurse, or appropriate technician to observe and/or help you with procedures. 

Medical Records

1. Admission History and Physical Examination. For each patient you admit, you must write a complete history and physical, utilizing standard format, followed by a patient-oriented assessment. Work-ups should be turned in to your attending physician within 2 days of admission (i.e., if patients is admitted on Monday, written up is due on Wednesday).

2. Progress Notes: Always use SOAP format. You must write daily notes on each patient. The notes must be reviewed, corrected, and signed by your intern the day they are written.

Presentations (Rounds/Conferences)

1. Use minimal notes. (It is permissible to have a 3 x 5 card with pertinent lab data.)

2. Give concise, succinct, well-organized presentations. (Less than 5 minutes.)

3. The following is a standard acceptable form to use for patient presentations:

   • Pertinent history. (Always begin with patient's age & chief complaint, followed by HPI, and PMH, ROS only as pertinent.
   • Pertinent physical findings.
   • Lab data. (blood work, EKG, X-rays, etc.)
   • Assessment, including differential diagnosis; concise statement of your assessment of patient's problem(s).
   • Plan for care, including diagnostic and therapeutic interventions.

4. Prepare in advance for your presentation for rounds (consider practicing the presentation to your intern or fellow student).

5. Keep up with your patients (symptoms, lab data, and physical findings) and be ready to give a brief summary at any time.

6. READ in standard textbook of medicine about your patient's disease(s) before rounds.