Jason Haag

Intern Conference
 Plan ahead
Use Resident Assistants to

Make follow up appointments

On WebCis f/u lists

Fax discharge summaries/patient information

 Plan ahead
Talk to your patient

How do they pay for meds?

Who is going to pick them out?

How long will the hospital stay be?

Who do they live with at home?

Do they have home health/home PT already in place?

 Start your discharge summary
Can put in procedures
Secondary diagnosis
Follow up appointments
Pertinent labs
Start the hospital course
 Brief Discharge Summary
Most important take home message to patients
Diagnosis
what you have/had done
Medications
***reconciled with home list***
Discharge instructions
What to do/what to look out for
Follow up appointments
Does not have to be exact date
 Talk with Social Worker
Be very nice to these people
About
Ride
They can provide one (ambulance, taxi, bus)
Medications
They can help pay for them (pharm assistance)
Home Health/Home PT
They can arrange it
 Talk with the Nurses
Keep them in the loop
Nurses will provide
Patient education
How do I administer lovenox, do accuchecks?
They will decipher your discharge summary into
patient talk
Make sure they understand whats going on with the
patient
 Talk with Home Infusion
Talk early and often

They provide home IV therapy

Can arrange IV therapy on Saturday
Can arrange acute changes in antibiotic choice
IF they know about the patient ahead of time
 Communicate with PCP
Dont have to call
Send phone message with dx/tx
Not a novel (they can read your d/c summary), just
give them a heads up
 TALK WITH THE PATIENT!!!!!!!!!
They will have questions that they want their doctor
to answer
The more time you put in early in the day answering
questions will save you later
 Key Points
Carry over all diagnosis
Reconcile medication list
Procedures/imaging
No need to list every CXR, KUB
Pertinent Labs
Admission Chem-10, CBC
Special labs
 Hospital Course
List by problems
Overview of hospitalization
Not on HD#1then on HD#2
Express the maximum amount of information in the
minimum amount of space
Be clear, concise, and coherent
The longer it is, the less likely someone is to read it
 Must do Brief Discharge Summary

To dictate or not to dictate

+/- of dictation

If you start falling behind

They will find you
Medical Records keeps a log of physician of record and
will track you down for delinquent d/c summaries
If you are too delinquent they wont let you work (i.e. wont
pay you) till your caught up