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Guidelines for Medical Students on the Inpatient Service

Guidelines for Patient Work-ups

Students should follow a maximum of 5 patients at any one time.  Each student should try to work-up 1 new patient each night on call, using the guidelines below: 

1. The history and physical examination must be performed and written in the chart within 24 hours after admission. These work-ups should follow the outline in your syllabus. Drawings are helpful for the documentation of physical findings.

2. Following the written history and physical exam, there should be an assessment and plan for patient management including appropriate plans for diagnostic studies, therapeutic interventions, and patient or parent education. The student and house officer should work as a team to avoid any duplication.

3. No order is to be written by students without first discussing it with the house officer. All student orders must be countersigned before they can be taken off by the nurse. 
4. These patients should be followed with daily progress notes.  Please discuss the content of the note with the resident so that you can be sure it is accurate.  Use the SOAP format:

Problem #                           (Title)

S — Subjective Complaints

O — Objective Data

A — Assessment

P — Plan Including Patient/Parent Education

5. Both residents and attending physicians are available to review new patient write-ups and progress notes. Ask Residents and Attendings for feedback on your write-ups. Discuss problems and questions with them. 
6. All new patients for a given day will be assigned on the floor by the supervising resident. Students will be responsible to find out when the patient has arrived. The best way to know is through the ward secretary or nurse. 
7. An off-service note (summary) should be written by the student for all patient charts that he/she signs off.

Guidelines for Patient Presentations for Rounds

The purpose of presenting a patient is to learn and to communicate to others what you have learned. In the process of learning, Synthesis of data is critical for the decision making process. Too often a prolonged nebulous history is presented and the attending physician cannot decipher what it is or where it is that the presenter is going. A logical discussion cannot follow. It is the presenter's responsibility as much as the attending's to make a good teaching session. A good presentation seldom requires more than five minutes, and most should be three minutes or less.

1. An example of an Initial Presentation is as follows:

   The child's name, age, and gender is given along with the chief complaint. The referring physician's name and location should also be noted. What follows is a brief description of the history of present illness, presented chronologically.  Include relevant details, and review of systems issues that are pertinent to the chief complaint. Then succinctly present the past medical history including relevant comments about dietary history, development (or school performance), immunization history, social history, hospitalizations, family history, and review of systems. 

   This is followed by a description of the physical examination. Give relevant vital signs, weight, height, and head circumference (with percentiles), then a general description of how the patient looks, followed by pertinent positive and negative findings on the physical examination.

   Make a problem-oriented assessment of your patient. For example:  "Jimmy Snort is a 5 year old boy with cerebral palsy and gastroesophageal reflux who presents with acute respiratory distress and fever, most likely a pneumonia due to aspiration."

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School of Medicine | Medical College of Georgia

Please email comments, suggestions or questions to
Dr. Lisa Leggio, lleggio@mcg.edu

June 29, 2006