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Patient
Care Responsibilities
Patients
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During your rotation on Surgery, 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.
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Always discuss up-coming issues regarding diagnosis, prognosis, or
management with your housestaff and attending before talking with patients and
family. It is always acceptable to tell a patient "I don't know, but I will
check with Dr. X for you." Never give a patient information about anything
unless you are absolutely certain about it.
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Patients have a right to refuse any care or
treatment. If a patient says "don't touch me," don't touch them! Do report
this to your resident or attending physician.
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You are required to enter your core general
surgery and surgical subspecialty patient encounters in the One45 System.
You should include all patients that you personally work up in clinic or
work up or follow in the hospital AND those you see on emergency call
and trauma call. Patients you see in off-service clinics should also be
entered. If you see more than ten patients in a clinic you may choose to
enter only ten. Pocket log books will be provided so that you can easily
list patients that you see when you see them and enter them at the end of
the day. We will check the One45 system at the end of each week of each
rotation. Points for 'professionalism" will not be given if you have not
entered your patients in a timely fashion. If for some reason you see only a
small number of patients during any week of your rotation (e.g., slow week
on an all inpatient service) email Dr. Nesbit and Grace Piaia explaining
why.
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 without direct supervision. You should ask a houseofficer, nurse, or appropriate
technician to observe and/or help you with procedures and have approval from the
house officer or attending before you do any procedure alone.
Medical Records
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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.
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Progress notes: Always use SOAP format. You should write daily notes on each
patient. The notes must be reviewed, corrected, and signed by your intern or
resident the
day they are written.
Presentations (Rounds/Conferences)
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The appropriate length and
detail of a presentation vary with circumstances. New patients are presented
in more detail than patients on whom you have rounded before. Get feedback
from housestaff or attending on how much detail they want. Use minimal notes. (It is permissible to have a 3 x 5 card with pertinent
lab data.)
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Give concise, succinct, well-organized presentations.
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The following is a standard acceptable form to use for patient
presentations:
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Pertinent history. (Always begin with patient's age and chief complaint,
followed by HPI, and PMH, ROS only as pertinent.)
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Pertinent physical findings.
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Lab data. (blood work, EKG, X-rays, etc.)
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Assessment, including differential diagnosis; concise statement of
your assessment of patient's problem(s).
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Plan for care, including diagnostic and therapeutic interventions.
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Prepare in advance for your presentation for rounds (consider practicing
the presentation to your intern or fellow student).
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Keep up with your patients (symptoms, lab data, and physical findings) and
be ready to give a brief summary at any time.
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READ in standard textbook of surgery about your patient's disease(s)
before rounds.
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