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Palomar ED Orientation
Welcome to your Palomar Emergency Medicine rotation. My name is Dr. Nicholle Bromley, and I am the Director of the Residency Program at Palomar Medical Center and Associate Medical Director of the ED. I will be your point of contact for scheduling of shifts and any issues that arise. I look forward to meeting and working with all of you. I will reach out to your prior to your rotation for schedule requests. You can always send those to me via email (nbromley@ema.us). I always try by best to accomidate requets but please keep them to a minimum. All residents are required to work some weekends and nights. Shift times are list below. Once you are cleared by the Palomar Medical Staff Office (usually a 1-3 weeks before your rotation date) I will send you a welcome email with information about the rotation. Every resident needs to attend orietnation on their first day. You will need to arrive 1 hours before your first shift and you will meet the Physician onboarding team(Nadelle and/or Tiffany) outside the main hospital enterance at the security check in. They will review the EMR and ensure you have appropriate IT access.
Orientations Times
• 9:00a shift meets at 8:00a
• 1:00p shift meets at 12:00p
• 2:00p shift meets at 1:00p
*if there are two residents starting the same day we will have you both meet at 12:00p.
We have 3 programs(UCSD EM, Navy Balboa EM and Camp Pendelton Family Med) with over 50 residents that start on different dates and times and so this site provides an over view for orientation and it is expected that you review the videos and written materials on this site prior to your start.
Contact Info: nbromley@ema.us, cell 858-344-8035
Where:
Palomar Medical Center, Escondido: 2185 Citracado Parkway, Escondido, Ca 92029
You need to obtain a parking sticker when you pick up your badge in the security office on your fist day. Park on the 5th or 6th floor to avoid receiving a ticket.
Orientation Outline
Rotating EM Resident Google Schedule
Expectations
Evaluation
Map of the ED
ED Shift Layout
EMA Dragon Commands
EMR Video Tutorials *please watch before your first shift
Palomar Charting Checklist
EXPECTATIONS
Show up on time and introduce yourself to the attendings on shift. If your are running late please call Pod B (442-281-5102) to let your attending know.
If you must call out of a shift due to illness or an emergency, text or call 858-344-8035 and send email to Nbromley@ema.us and CC your program director.
If you need to trade or change a shift, all requests must be approved by Dr Bromley by sending emailNBromley@ema.us. We have multiple residency programs, and the Master Google Schedule needs to stay up to date.
USE the CHARTING CHECKLIST to avoid making errors or sending incomplete charts which can lead to additional work for you after completing your shifts. As of January 1st,the guidelines for E/M coding have changed. One of the biggest changes as of 2023 is that you are no longer required to have a specific number of elements in your HPI, ROS, PMSFHx, and physical exam, however, the MDM is now extremely important. Please review the charting checklist. You may want to print a copy and bring it to your shift
Please complete ALL charts prior to leaving your shift, you will NOT have remote access. If a chart is incomplete you may be required to come back to the hospital to complete it in a timely matter.
Residents should attend the trauma team activations: Priority for procedures goes to the resident scheduled for the 5a/1p/9p shift but if there is no resident on for those times then please attend to the traumas.
In general, residents will see patients anywhere once they self-assign (i.e. signup for a patient). However, you may be asked by another attending that is working in a different area to help with a critical case, a procedure, or the Trauma's, Stroke's or STEMI's as above.
Attending supervision: Residents must identify themselves to patients as “resident physician” working with Dr. X. Attending must supervise/see and dictate on all patients seen by the resident. The note must include documentation of the history, exam and medical decision making. The attending must counter sign the medical record of each patient seen by the resident and review the care plan. The attending or supervising staff must supervise all procedures.
GENERAL LAYOUT AT PALOMAR HOSPITAL
There are 4 "PODS" in our ED: A, B, C, D and additional areas that are used for patient care. They are broken up into 3 different sections with some overlap.
1. Anchor Shifts: See patients in POD A, B, C, Cardiac room, Offload line and Front Care (if you have the capacity and there are no patients to be seen in the back. These shifts are broken down into the Trauma shift and Stroke Shift. Attendings typically will sit in POD B.
Trauma 5a/1p/9p: If you are assigned to this shift, you are responsible for all Trauma team activations.
Stroke 6a/2p/10p: If you are assigned to this shift, you are responsible for all Stroke Code activations and Emergency Response Team Activations (Code Blue on 2ndfloor and in public spaces)
** If you are the only resident on, you can present cases to either attending, however, if there are two residents at the same time, please present to the attending that is working the same shift as you.
2. Pod D: 9a/12p/5p: Only Camp Pendleton Family Medicine residents will be assigned shifts
3. Front Care Shifts (not assigned to residents but can see patients in this area if there are no
patients to see in the back)
End of shift evaluation.pdfEMR Video Tutorials
Click on links below
Overview of the Tracking Board(How to check in, add name/phone#,dragon window) (not available yet)
Tracking board filters NPMC/POD D, How to sign up for a patient (not available yet)
How to generate a note, sign and send to attending for cosignature (not available yet)
How to document informed consent & procedures **VERY IMPORTANT
EMA Dragon Commands
Palomar uses Dragon(DMO) for dictating notes. Each computer will have a mircophone to use.
EMA has a large library of Dragon commands that can be used(a copy was sent your welcome email)
The EMA dragon command consist of pretemplated physical exams, MDMs, critical care, procedure notes, radiograph templtes etc
Please use My Sepsis and My Code Stroke when indicated. These have important reminders and core measures that need to be documented
Please add My Resident to the top of your MDM for every note. This is very important for billing
You can use 'MY ED COURSE' in the MDM section as a comprehensive way to document labs, rads, course, MDM, etc.
Remember to use MY CRITICAL CARE TIME, MY OBSERVATIONS and MY RESTRAINTS
PALOMAR CHARTING CHECKLIST
As of January 1st, the guidelines for E/M coding have changed. One of the biggest changes as of 2023 is that you are no longer required to have a specific number of elements in your HPI, ROS, PMSFHx, and physical exam.
Previously, chart complexity was determined based on the detail of these sections. Even with these changes, don’t forget that a comprehensive HPI and exam is still important so that that there is enough information to communicate clearly with the patient’s care team, provide legal protection and effectively communicate the complexity of the visit to the coders. Going forward, the chart complexity will focus on medical decision making (MDM), especially the number and complexity of the problems addressed. As a result, documentation needs to focus more on each individual problem assessed AS WELL as ones you considered but ruled out. With these changes there will also be consideration of prudent layperson support regarding the final diagnosis. Per 2023 CPT E/M Descriptors & Guidelines July 1st release “The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.” This means that if the patient presents with chest pains and the final diagnosis is acid reflux, the chart can still be billed as a level 5.
1. Resident Supervisory Statement (MOST COMMONLY MISSED BY RESIDENTS) use EMA Dragon Command "My Resident" add to the top section for the MDM
"I the resident physician attest that I examined the patient and performed the services as described with the attending physician present during the critical or key portions of the service. "
2. HPI- make sure there is enough information to communicate clearly with the patient’s care team, provide legal protection and effectively communicate the complexity of the visit to the coders.
3. ROS – no longer needed. Remember to include pertinent positives and negatives in the HPI
4. Past Medical, Surgical, Family, and Social History - please update under "consolidated problems" on provider view page
5. Physical Exam – Document relevant to presentation
6. EKG documentation
All EKG interpretations must have
The time of the EKG
STATE THAT IT WAS YOUR INTEROPERATION
At least 3 elements.
7. Include all labs, procedure notes and critical care time if applicable.
8. Imaging: will auto import into your note when you genergate a ED PROVIDER NOTE
9. Document repsonse to interventions/medications
10. Consults/Discussion with family- document time, who you spoke with, summary of info obtained/recommendations
11. Document review of other notes/info- Nursing home notes, EMS run sheets, previous hospitalizations, office records etc. (review of previous ED notes are excluded)
12. Medical Decision-Making Paragraph: THIS IS THE MOST IMPORTANT SECTION. This is filled in the “Re-examination” Section. Details about the visit with support for your thought process regarding admission or discharge as well as treatments given and noted improvement or stability. Be thorough in this section.
- Discuss comorbidities of everything you are treating:
Example: If someone presents for cellulitis and you are treating it but they are also diabetic, discuss that they are diabetic and whether or not you are addressing the blood glucose. Did you also give them IV fluids because their glucose was 300? Do they also have a preexisting condition such as hypertension and did you address it?
- Document ALL treatment/tests considered:
1. Even if tests were not ordered or unnecessary. The reasoning behind this is that it is the same amount of work to consider something as it is doing it
2. Consider decision rules to describe your thought process/severity
i. PECARN, OTTAWA, WELLS, PERC, PEDS APPY SCORE, etc
ii. For example: In a patient with negative d-dimer and Wells resulting in low probability for PE, document this is why you did not obtain CTA PE study
iii. Another example: Applied PECARN for a child head trauma and determined no need for CT head
3. Did you consider antibiotics for a patient with fever but decided it was not necessary?
· Sample documentation “MY ADULT/PEDIATRIC URI”: This is an otherwise healthy, well appearing patient presenting with uncomplicated URI symptoms, likely viral in etiology. Patient is non-toxic and well hydrated. I have reviewed the vital signs and there is no evidence of [***clinically significant hypoxia]. [***I have low clinical suspicion for pneumonia, meningitis or other significant bacterial disease]. Patient will be treated with outpatient supportive care; no antibiotics indicated at this time.
4. Did you consider admitting the patient? Did you speak to patient about it? Did you engage in shared-decision making?
i. i. Even if patient goes home, document these conversations as it increases the complexity of the chart.
ii. ii. At EMA we have several shared decision-making tools including our PE in Pregnancy Pathway (click here) as well as our pediatric head trauma voice recognition command
iii. iii. To view the MY PEDIATRIC HEAD TRAUMA command in its entirety, (click here), but the pertinent shared decision making discussion is as follows; “If YES to any of the above, shared decision making occurred with the parent(s). I discussed the options of observation versus CT Head, and the 0.9% risk of clinically significant traumatic brain injury. Parents and I decided [***].
5. Is the patient requesting unnecessary tests? .
· Did you have an extensive discussion with patient about risks vs benefits of ordering these tests and shared decision making resulted in them not being ordered? Then document and you will get credit for this work!
6. If there is an exacerbation of a chronic process please use an appropriate modifier to describe the severity: i.e. severe acute exacerbation of COPD, mild worsening renal failure, etc
13. Document social determinates of health: For example if patient is illiterate, no access to housing, or other healthcare resources have to be considered it increases the complexity of the chart.
· Sample verbiage of documentation that you can start including now in your MDMs: “Diagnosis or treatment significantly limited by the following social determinants of health: [inability to afford prescribed medications, unavailability/inaccessibility of healthcare, homelessness, unemployed, uninsured, substance abuse, ***]
· Voice command example “My Homeless Discharge”
I have provided a medical screening exam and evaluation. Referral to outpatient behavioral health for follow up is [***not indicated / ***indicated and referrals were provided.]
The patient is clinically stable for discharge. I have communicated after-visit instructions and plan to the patient.
Because patient has been identified as without residence, the hospital policy and process for discharge requirements have been initiated by appropriate hospital staff
14. Final Diagnosis
- 1 or more diagnoses in order of importance. You can use the ICD finder for
diagnoses here. Better to be thorough here not just the admitting diagnosis
- e.g. Acute chest pain, chronic hypertension, chronic hyperlipidemia, etc.
- For example: Don’t just put the chief complaint of acute chest pain but also note all
other findings, i.e. shortness of breath, acute respiratory failure, hypotension, acute
renal failure, hypokalemia, hyperglycemia, etc…
15. Disposition
- Did you admit or discharge the patient. If admit, list admitting- attending name. If discharge, include DC instructions and rx’s given.
16. Scribe coverage is limited and only for the attending physicians, however, they are always available to help with charting questions
17. Forward notes to your attending for signing :
1. Request Endorsement when signing note
2. After the note is complete and ready to be signed be sure to follow these steps to assure the note is sent to the supervising MD for cosignature. When you click ‘Sign’ the following popup will occur.
3. Check the box titled ‘Request Endorsement’. When you do a yellow line will appear:
4. Click under ‘Endorser’ and enter the MDs name. You can click the binoculars to search for the name if you are not sure of the spelling.
5. Under ‘type’ select ‘Sign’, not ‘Review’. You do not need to enter anything under ‘Due By’ or
6. ‘Comment’. After this click ‘OK’ to sign your note and send it to the Attending MD for signature.
7. If you have trouble then ask the scribe how to do this
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