For billing purposes, you must list individually 12 systems with 2 components each or include a single blanket statement like “a comprehensive, 12-point review of systems was performed and was negative except as mentioned above in the HPI.” Physical Exam: (Include 10 systems with at least 2 points each) Vital Signs (including pain scale if appropriate) General Appearance: Eyes: Ears, Nose, Throat: Neck: Cardiovascular: Respiratory: Chest/Breast: Gastrointestinal (abdominal): (Including Rectal when appropriate) Genitourinary (Male/Female): (when appropriate) Lymphatic: Musculoskeletal: Skin: Neurological: Psychiatric: Laboratories: Imaging/Diagnostics: Include “Personally reviewed by me…” (when appropriate) Include any x-rays, CT scans, other recent radiology studies, EKG interpretation, etc. Assessment/Impression: The assessment and plan are the most important components of your dictation. Everything above here is data collection. This is where you organize your thoughts and demonstrate your knowledge! Your assessment should be a summary of all of the above data, based on the subjective and objective information you have available at the time of admission. Often the Assessment & Plan are the only parts of a dictation that are read by nurses, consultants, etc. If a diagnosis is clear (ie pneumothorax), say that. However, do not diagnose a patient with a condition without it being 100% certain of it, as your dictation will be used in the future for many purposes and the diagnosis you assign your patient will follow them for life. For example, if you are admitting a patient with shortness of breath, you should not diagnose them with COPD without verifying that the patient has had PFT’s to definitively diagnose COPD. If you dictate “COPD exacerbation” and the patient turns out to have only pneumonia with no
JUNIOR INTERNS (JI) RESPONSIBILITIES/EXPECTATIONS TO: All faculty, residents, and interns on service FROM: Gary Malakoff, MD, FACP, Medicine Clerkship Director DATE: July 1, 2013 RE: M4 Medical Students – JI 1. JI’s function as interns - directly under the supervision of the resident on the team. 2. Take “ownership” of your patients. JIs are expected to pre-round on their patients before work rounds start for the day. 3. Daily SOAP notes should be written on all new patients (corrected and by the resident). 4. Complete written H&P’s should be written on all new patients (corrected and co-signed by the resident. 5. JI’s are expected to call consults in the standard manner on all of their patients should they require it. 6. Orders should be written by the JI on all of his/her patients. These must be co-signed by the resident before the nursing staff can take them off. It is the JI’s responsibility to make sure that orders are not taken off until they are co-signed. Page 2 – JI Responsibilities 7. JI’s have the same call schedule as the team they are assigned to work with.
8. JI’s may admit at least one patient and up to three per call night. 9. JI’s should follow up to 5 patients at any one time. 10. JI’s do not dictate the Discharge Summary. 11. JI’s are expected to attend all conferences (morning report, noon conference, Grand Rounds, Chairs Rounds, etc.) 12. JI’s are supervised by the resident. 13. The 80 hour work week applies to JI’s. 14. JI’s are expected to have on average, 1 day off in 7 and not during the week. 15. JI days off should be the same as the interns (the resident will cover the JI patients when the JI is off). 16. Duty hour rules apply to the JI as they do to all house staff. 17. Feedback should be timely and include: ● A written and signed Mid-Month evaluation given by the resident and attending physician (this includes a face-to-face meeting between the resident/attending and the student) ● A final written evaluation given by the resident and attending physician 18. Grading is based on 100% clinical evaluations. 19. Concerns about professionalism, poor performance, etc. should be brought to the attention of the Clerkship Director and ward attending as soon as possible. INTERNAL MEDICINE CLERKSHIP History and Physical Form Student Name: ______________________ Attending/Resident:___________________ Attending/Resident signature: _________________ HPI: I. Chief Complaint Present and clearly identified? (Please circle) Y N
FACULTY: Please complete, sign, and return directly to student. If the score is not zero, you may have the student revise the H&P until it meets the minimum criteria above. I have received and read the Policies and Procedures and Graduation Requirements of the Department of Medicine. I understand the policy for advancement and graduation from the Residency Program. ___________________________________________ Signature ___________________________________________ Print Name ___________________________________________ Date