Components of the “Assessment and Plan”
# Problem: most likely due to ... given the history, clinical presentation... in a ..yo, man/woman with multiple risk factors..... other possibilites in DDx include....
etiology or differential diagnosis (and examine the points in favor and against each differential diagnosie)
current status
physical findings, laboratory data, radiological data to support current status
what you will do next
Order your problems such that the "Unknown Problems" (problems you do not yet know the diagnosis) come first, followed by the "Conditions that require active management" (like uncontrolled DM or uncontrolled HTN), followed by "Stable Conditions" (e.g....unchanged anemia, hypothyroidism that is clinically and serologically euthyroid...etc....), and then list "prophylaxis" and "disposition," and code-status.
Initial Patient Work-up
complete History and Physical (don’t forget fundus, rectal, pelvic exams and sputum gram stains, urine microscopy and peripheral smear when appropriate).
obtain old medical record (call 6-3156)
look back in CIS to 1997
contact patient’s family if patient cannot make his/her own medical decisions or give their own history
discuss the case with attending physician and ask for their choice of consultants if needed
contact any specialist/consultant
determine code status
please make sure there is a Yellow cross-coverage sheet and Blue Problem List card in every patient's chart (both are available in the department of medicine)
Follow-up Patient Work-up (prior to AM rounds)
see and examine your patient. Ask for any problems overnight. Check vitals. Manually confirm any abnormal vitals.
if patient is crashing, CALL YOUR RESIDENT IMMEDIATELY.
review the chart. Read consultants notes, cross-coverage notes, nurses notes.
review the order sheet for any new orders written by others.
review the MAR every 2-3 days to ensure its accuracy
I encourage you to finish your progress notes (SOAP format) before AM rounds. This isn't always possible, but it does make the rest of your day go smoother.
All pages of your notes MUST have a time and date and heading at the top (e.g…A Medicine Intern). Please ensure that there is a patient ID sticker at the top right hand corner.
If you are discharging the patient that day, YOU MUST inform the attending physician prior to doing so.
It is always a good idea to call your consultants before discharging your patient for any final recommendations and follow-up.
***For all patients that you see on cross-coverage, you must write a note in the chart (entitled “A-Medicine Cross Coverage”) to prove that you saw the patient. Document why you were called to see the patient and write a brief SOAP note.***
As always, please call your resident at anytime for questions about your patients or cross-coverage.