The Art of Roundsmanship
Handouts created by:
Honors Consortium (AOA, Gold Humanism Honors Society, Landacre Honors Society)
and Student Council
The following documents are intended to help smooth your transition into new rotations by giving you suggestions for
commonly covered topics on rounds for each rotation. Included documents are listed below. These are, of course, only
general suggestions created for the most part by students, and you should modify as needed for either your patient’s or
your team’s needs.
Medicine SOAP note – meant to be filled in on rounds, with helpful mnemonics following
Surgery SOAP note – similar to medicine soap, with surgery mnemonics
OB/Gyn SOAP notes as well as templates for other helpful notes, and menemonics following
Neurology SOAP note template and helpful neurology information
Psychiatry scut sheet – helpful for keeping track of history and has a place to record daily updates – from
medfools.com
6) Antibiotics reference chart – this is a modified version of the handout you will get during IM, but it is helpful for
all rotations, so we thought you might want it now.
7) EResults quick reference – abbreviated version of the handout in your GHHS Guide to Clinical Clerkships to
keep in your coat pocket
1)
2)
3)
4)
5)
Date
Time:
MS3 Progress Note (medicine)
S:
Interval history?
Pain?
Appetite?
NOW THINK: what is happening with my patient? Anything special I need to think about/look for on exam? Anything I
don’t understand about what is happening with them?
O: VS: Tm
I/O:
Tc
P
R
BP
Sat
on
Gen:
HEENT:
Lungs:
C/V:
Abd:
Extremities:
Neuro:
Antibiotics?
Pain meds?
DVT prophylaxis?
Diet:
Labs:
Cultures
Imaging
A/P
Day
of
GI prophylaxis?
Fluids?
Rate?
Hypercalcemia Etiologies - CHIMPANZEES
C - Calcium overdose (don’t usually mention this one)
H - Hyperparathyroidism, Hyperthyroidism, Hypothyroidism, familial Hypercalcemic hypocalciuria
I - Immobility
M - Multiple myeloma
P – Paget’s disease
A – Addison’s disease
N – Neoplasms:
- metastasis to bones and
- hypercalcemia of malignancy (a paraneoplastic syndrome)
Z – Zollinger-Ellison syndrome
E – Excess vitamin A
E – Excess vitamin D
S – Sarcoidosis
Indications for Acute Hemodialysis - AEIOU
A – Acidosis (unable to be managed medically)
E – Electrolytes (typically hyperkalemia, unable to be managed medically)
I – Intoxication (methanol, ethylene glycol, lithium)
O – Overload (fluid overload unresponsive to diuretics)
U – Uremia (symptomatic)
Causes of delirium – MOVE, STUPID
Metabolic
Oxygen
Vascular
Endocrine/Electrolyte
Seizures
Tumor/Trauma/Temperature
Uremia
Psychogenic
Infection/Intoxication
Drugs/Degenerative disease
Causes of metabolic acidosis with an anion gap – MUD PILES
M – methanol
U – uremia
D – diabetic ketoacidosis
P – para-aldehyde
I – Isoniazid, iron, inborn errors in metabolism
L – lactic acidosis
E – ethanol, ethylene glycol
S – salicylates
Treatment of Acute MI – MONA
M - morphine
O - oxygen
N - nitrates
A – aspirin
Date
Time:
MS3 Progress Note (surgery)
S:
Interval history?
Pain?
Bowel movement?
Nausea/vomiting?
Flatus?
Appetite?
NOW THINK: what is happening with my patient? Anything special I need to think about? Anything I don’t understand
about what is happening with them?
O: VS: Tm
I/O:
Tc
P
R
BP
Drains?
Sat
on
Gen: Sick vs well appearing?
Lungs:
C/V:
Abd: Distention? BS? Soft? Tenderness? Guarding? Rebound?
Wound: where? Clean? Dry? Intact? Erythema? Drainage?
Extremities: Tenderness? Swelling? Warm?
Antibiotics?
Pain meds?
DVT prophylaxis?
Diet:
Labs:
Cultures
Imaging
A/P
Day
of
GI prophylaxis?
Fluids
Rate?
Etiologies of Postop Fever
The 5 W’s
Wind (atelectasis, pneumonia)
Water: UTI
Wound: infection
Walking: DVT/PE
Wonder drugs: drug fever
Causes of Panceatitis
I GET SMASHED
Idiopathic
Fistulas: conditions preventing closure
HIS FRIEND:
High output (>500mL/day)
Intestinal destruction
Short segment (<2.5cm)
Scorpion bites
Mumps (viruses)
Infection
Autoimmune
Steroids
Hyperliidemia
ERCP
Drugs
Foreign body
Radiation
Infection
Epithelialization
Neoplasm
Distal obstruction
Gallstones
Ethanol
Trauma
Causes of GI bleeding
ABCDEFGHI
Angiodysplasia
Bowel cancer
Colitis
Diverticulosis/ Duodenal ulcer
Epistaxis/ Esophageal (cancer, esophagitis, varices)
Fistula (anal, aortoenteric)
Gastric (cancer, ulcer, gastritis)
Hemorrhoids
Infectious diarrhea/ IBD/ Ischemic bowel
Causes of a unilateral swollen leg
TV BAIL:
Trauma
Venous (varicose veins, DVT, venous insufficiency)
Baker's cyst
Allergy
Inflammation (cellulitis)
Lymphedema
Treatment of acute pancreatitis
MACHINES:
Monitor vital signs
Analgesia/ Antibiotics
Calcium gluconate (if deemed necessary)
H2 receptor antagonist
IV access/ IV fluids
NPO
Empty gastric contents (NG tube)
Surgery if required/ Senior review
Examples of other Notes for OB/Gyn
MS H&P
S: Pt is a 20 y.o G4P1112 (Grava 1, Para 1 (term), 1 (preterm), 1 (abortions), 2 (living)) at 39+1 weeks by 10
week ultrasound c/w LMP (consistent with last menstrual period) who presents to L&D (labor and delivery) in
labor. Pregnancy has been uncomplicated. + FM (Fetal movement), denies LOF (loss of fluid), VB (vaginal
bleeding). Ctx (contractions) q 4 minutes
ROS: Among other things, be sure to ask about headaches, visual changes, abdominal pain (especially RUQ
pain), worsening non dependent edema, change in urinary habits
PMH: asthma, does not take meds now
PSH: Tonsillectomy as a child
Meds: PNV (prenatal vitamin)
Allergies: Penicillin -> anaphylaxis
POBHX: G1 - 35 week SVD (spontaneous vaginal delivery) of VMI (viable male infant) 5 lbs, 2 oz
G2 - 8 week, SpAB (spontaneous abortion)
G3 - 40 week, LTCS (low transverse Cesarean section) for breech
G4 - Current
PGYNHx: No hx of STDs,
+ hx of abnormal PAP with LEEP, but all PAPs normal since then
Menarche at 13 years of age w regular periods q 28 dys lasting 4-5 days, no menorrhagia
SH: tobacco (1.5 PPD), denies use of alcohol or illicit drugs
FH: No history of birth defects
No history of bleeding or clotting disorders
No history of multiple gestations
DM - grandmother
Emphysema - paternal grandfather
PE Temp, BP, HR, RR
Labs: A+ (blood type), antibody -, rubella immune, RPR NR (non reactive), HBSag negative, HIV
negative, GBS (group B strep) positive, 1 hour glucola 63, GC and Chlamydia negative; CBC (complete blood
count)...
A/P: 20 yo G4P1112 at 39+1 weeks who presents in labor currently 4 cm dilated, 90% effaced and -1 station
1) Admit to L&D
2) Epidural when desired
3) Clindamycin for +GBS and penicillin allergy
4) AROM (artificial rupture of membranes) after 4 hours of antibiotics
MS Triage Note
S: pt is a 20 y.o. G2P1 at 37+1 weeks by 8 week ultrasound that is consistent w LMP, presents to L&D with
complaints of ctxs. No LOF, VB. + FM
O: Temp, BP, HR, RR, T
Abd: soft, gravid, NT (non tender)
Ext: 1+ edema bilaterally, NT
FHT (fetal heart tones): 140, moderate variability
TOCO (tocometer): ctxs q 9 minutes
Cervix: 1/40/-3 (dilation/effacement/station) (per RN)
A/P: Pt is a 20 y.o G2P1 at 37+1 weeks who presents for rule out labor
1) Will have patient walk for 1 hour after getting reactive FHT, then recheck cervix
MS Delivery Note
SVD (spontaneous vaginal delivery) of VMI (viable male infant) with APGARs 8, 9 over 2nd degree midline
laceration. Head delivered atraumatically, mouth and nose bulb suctioned at perineum, loose nuchal cord x 1
easily reduced, shoulders and body delivered without delay or force. Cord clamped and cut and infant handed
to awaiting RN. Cord gases obtained. Spontaneous delivery of placenta with 3 VC (vessel cord) intact. No
cervical, vaginal vault or periurethral lacerations. 2nd degree midline laceration repaired with 3.0 vicryl suture.
EBL (estimated blood loss): 300 cc
Anesthesia: Epidural
Dr. (attending) present
MS Operative Note
Pre-operative diagnosis: IUP (intrauterine pregnancy) at term, breech presentation
Post-operative diagnosis: same
Procedure: primary LTCS via Pfannensteil incision
Surgeon:
Assistant:
Anesthesia: spinal with duramorph
Findings: VFI (viable female infant), frank breech, APGARs 8,9, 3VC, intact placenta, normal ovaries
EBL (estimated blood loss): 800 cc
Fluids: 1800 cc crystalloid
UOP (urine output): 200 cc, clear
Packs/Drains: foley
Complications: none
Disposition: Patient and infant stable to PACU (post anesthesia care unit)
MS Post-op Check
S: Pt resting comfortably. Pain well-controlled. Minimal nausea. No vomiting.
O: Temp, BP, HR, RR
Gen: NAD, A&O x3
Abd: soft, appropriately tender, ND, absent BS
Inc: Dressing clean and intact
Ext: No edema, non-tender, SCDs in place
A/P: 47 y.o. WF POD #0 TAH/BSO
1) Hemodynamically stable, CBC in am
2) continue routine post-op care
MS HROB (High risk obstetrics/Maternal fetal medicine)
S: No complaints. Denies VB, LOF, ctx. +FM
O: Temp, BP, HR, RR
Gen: NAD, A&O x3
Abd: soft, gravid, non tender
Ext: No edema, non-tender, DTRs (deep tendon reflexes) 2+ bilaterally, SCDs in place
TOCO: No contractions
FHT: 135, moderate variability, reactive
A/P: 32 y.o. G1P0 at 30+1 weeks with PTL (preterm labor)
1) s/p BMZ (status post betamethasone)
2) Continue bed rest with BRP (bathroom privileges)
3) GBS negative
MS PPD (post partum day) #1
S: Pain?
Lochia?
Ambulating?
Breast/bottle feeding?
Pain meds used?.
Diet?.
Voiding?
Plan for contraception?
O: Temp
BP
HR
RR
Gen:
Lungs:
C/V:
Abd: soft? NT/ND? Fundus? (Should be firm, 2 finger breadths below umbilicus)
Ext: edema? Palpable cords?
DTRs:
Labs?
A/P: 19 y.o. PPD # __ SVD
1) MWB (maternal well being) - doing well, Rh + or - , RI (rubella immune)? Hgb?
2) FWB (fetal well being) – male/female infant, well?, breast/bottle feeding?, desires circumcision?
3) PPBC (post partum birth control)
4) D/C (discharge) planning
MS POD (post operative day) #1 from C/S (can be used for other Gyn surgeries, omitting lochia/fundus)
S:
Pain
Pain meds used?
Lochia?
nausea or vomiting?
Flatus?
Diet?
Ambulating?
Contraception?
O: Temp
BP
HR
RR
Gen:
Lungs:
C/V:
Abd: soft?
Appropriately tender?
Fundus?
BS?
Inc (incision): C/D/I (clean/dry/intact)?
Staples/sutures?
Ext: tenderness?
Edema?
SCDs (serial compression devices) in place?
Labs?
A/P: 55 y.o. WF POD #1 C/S
1) Hemodynamically stable, CBC?
2) advance diet to clears, await flatus for regular diet
3) ambulate with assistance, continue incentive spirometry
HELLP syndrome
Hemolysis
Elevated LFTs
Low Platelets
Risk factors for Preterm Labor - MAPPS
Multiple gestations
Abdominal surgery during pregnancy
Previous Preterm labor
Previous Preterm delivery
Surgery of the cervix
Contraindications to tocolytics –
CHAMPS
Chorioamnionitis
Hemorrhage
Abruption
Maturity of fetus
Preeclampsia/eclampsia
Severe IUGR
Risk factors for shoulder dystocia –
MOMS on L&D
Maternal
Obesity
Macrosomia
Second stage prolonged
Late (post-date pregnancy)
Diabetes
Causes of fetal baseline tachycardia
FFAASTT Heart
Fetal infection
Fever
Arrhythia of fetus
Anemia of fetus
Sympathomimetics
Tacycardia of mother
Thyrotoxicosis of mother
Hypoxia
Causes of postpartum hemorrhage - 4T's
Tone diminished
- Uterine Atony represents 70% Postpartum hemorrhage
Tissue
- Retained Placenta
- Placenta accreta
Trauma
- Uterine Inversion
- Uterine Rupture
- Cervical Laceration
- Vaginal hematoma
Thrombin
- Coagulopathy
Neuro SOAP note template
Date, time
MS3PN
S: any complaints the pt has, how they are doing, what happened yesterday
O: Vitals (Tmax, Pulse (min-max), Respiration (min-max), BP (min-max), SaO2)
Ins and Outs (over 24h). *note last BM when going to Dodd
Exam:
General: how does patient appear?
CV: RRR (regular rate and rhythm)?, normal S1 and S2?, no m/r/g (murmurs/rubs/gallops)?, peripheral pulses 2+
bilaterally?, peripheral edema?
Lungs: CTAB (clear to auscultation bilaterally)?, no wheezes/rales/rhonchi?, no accessory muscle use?
Abd: soft?, NT/ND (nontender/nondistended)?, bowel sounds normal?, no palpable masses or organomegaly?
Mental Status: awake/somnolent/drowsy/arousable (to pain/name, etc?)/ comatose
CN : EOMI (extraoccular mvts intact), PERRLA (pupils equally round and reactive to light and accommodation), face
symmetric/droop, palate elevation symmetric/asymmetric, facial sensation intact ?/ tongue midline?
* what to test with CN’s
II: visual acuity, fields, pupils
III, IV, VII: extraoccular movements, corneal reflex (if you are mean)
V, VI: facial sensation, movement
IX, X, XII: palate tongue, gag reflex, shoulder shrug/SCM
Motor: tone (nl/spastic/flaccid)
Bulk: atrophy?
Strength:
SA/EF/EE/WE/WF/DI/HF/KE/DF/PF
R ____________________________________
L
*(shoulder abd, elbow flex, elbow ext, wrist flex, wrist ext, dorsal interossi, hip flex, knee flex, dorsiflexion,
plantarflextion) scale of 1-5 (5 = normal)
Coordination: finger to nose, heel to shin, rapid alternating movements
Sensory: safety pin prick/vibration/proprioception/temperature
Gait: stance/stride/ arm swing/tandem walk/steadiness with feet together & eyes closed
DTR (deep tendon reflexes)
O
\ | / *note biceps, triceps, brachioradialis, patellar, Achilles reflexes
| .
scale of 1 -4 (2 = normal)
/
\.
*annotate with arrows if toes are upgoing or downgoing.
Labs: Na |Cl |BUN /glucose
\ Hgb /
K |CO2|Cr \
WBC / Hct \ plt
MRI, CT studies, consults, etc.
A/P: “one liner” about pt “Mr Murphy is a 45 y/o right handed WM with a history of ___ who presented with _____.
Sometimes, make a comment about their condition if it has changed since admit “s/p (status post) TPA with improvement in
left leg weakness”
Problem list (can be done by problems or by systems)
1. Neuro ( a. problem or ddx/ b. diagnostic studies/ c. treatment plan )
2. Endo
3. Cardio
4. Etc…..
Joe Smith, MS3
346-xxxx (pager #)
DTRs:
Biceps = C5, C6
Brachioradialis = C5, C6
Triceps = C6, C7
Patellar = L4
NO L5 reflex
Achilles = S1
Dermatomes:
T4 = nipple line
T10 = umbilicus
L1 = inguinal ligament
Caloric eye testing – normal eye movements
COWS
Cold - Opposite
Warm - Same
MRI
T1 – image looks like brain – ie white matter is white, gray matter darker, CSF black, best for anatomy of brain
T2 – inverse of T1 – white matter is dark, gray matter lighter, CSF white, pathology stand out better (edema has a large water
component)
DWI – diffusion weighted images – type of T2 sequence that can identify ischemic areas within minutes of onset
Glasgow Coma Score – out of 15
Verbal
Eye opening
5 – oriented
4 – confused
3 – inappropriate words
2 – incomprehensible
1 – no response
4 – spontaneous
3 – to voice
2 – to painful stim
1 – no eye opening
Causes of delirium – MOVE, STUPID
Metabolic
Oxygen
Vascular
Endocrine/Electrolyte
Seizures
Tumor/Trauma/Temperature
Uremia
Psychogenic
Infection/Intoxication
Drugs/Degenerative disease
Motor
6 – follows commands
5 – localizes pain
4 – withdraws from pain
3 – flexion/decorticate posturing
2 – extension/decerebrate
1 – no response
Penicillins
Penicillin
IV/P
O
G+ only, All GAS/GBS, syphilis, oral anaerobes (but not gut),
clostridium
exudative pharyngitis, erysipelias
Nafcillin
(IV)/oxacillin(po)/dicloxacillin(po)
IV/P
O
G+ only DOC MSSA, can use for strep, (no MRSA), no G neg
Cellulitis, s. aureus cutaneous abscess
IV/P
O
G+ and some G- DOC for enterococcus, strep like pen, no
staph, only a little G neg (some H.flu, some e. coli), listeria
1st line acute otitis media, acute sinusitis, neonatoal
meningitis with gentamicin
aminopenicillins
Piperacillin
IV
Like amp + G-, so good for strep, enterococcus and G neg incl
pseudomonas + anaerobes, but NO MSSA
Amp/sulbactam (unasyn) IV
IV
Like amp + MSSA and anaerobes, NO MRSA, H.flu, most
anaerobes, listeria
Amox/clavulanate (augmentin) po
PO
Pipercillin/tazobactam (zosyn)
IV
All except MRSA, including pseudomonas and enteric G-
IV
No enterococci, NO MRSA, no listeria
Staph and strep in pen allergic pt (10% cross react), G pos,
few G neg (ex ecoli), few anaerobes
B lactamase resistant penicillins
Ampicillin(IV)/amoxicillin(po)
Pen + B lactamase inhib
(adds MSSA)
Failed tx of otitis media
Ticarcillin/tazo? (Timentin)
Cephalosporin
All
1st gen: Cefazolin (ancef) IV
Cephalexin (Keflex) PO
2nd gen: Cefoxitan (Mefoxin) iv
PO
IV
PO
Above + H.flu, more G neg, anaerobes
gut surg prophylaxis, otitis failed augmentin,
IV
A lot of G neg (no pseudomonas), not as good for staph as first
and second gen, still good for GAS/GBS and s.pneumo
Comm acquired Meningitis in all except neonates – crosses
BBB, also for pyelo in kids and adults
Rocephin, bad in neonates – biliary sludging/Ca++
precipitation, can use cefotaxime
Omnicef – otitis failed augmentin
IV
G pos, most G neg, incl pseudomonas, limited anaerobes, no
enterococcus
Cefpodoxime (Vantin) iv
Cefuroxime (Ceftin) po/iv
3rd gen: Ceftriaxone (Rocephin) im/iv
Cefotaxime (Claforin)
Cefdinir (omnicef) po
4th gen: Cefipime
Ceftazidime
Carbapenem
Meropenem (kids)
Nosocomial meningitis, pseudomonas
IV
Gram pos incl. entero, gram neg, pseudomonas, anaerobes,
ESBL gram neg, NO MRSA, no acinetobacter
Imipenem – decreases seizure threshold
IV
Like imipenem but no pseudomonas
Q day, no CNS penetration
IV/P
O
IV/P
O
Gram pos, some anaerobes, atypicals, NO gram neg
Can cause pyloric stenosis so CI in neonates
Above + H.flu, MAC tx, prophylaxis, more G- than erythro
Pretty good resp drug, Pen allergic for strep throat, otitis
media, DOC outpatient community acquired pneumonia in
teenagers/adults, pertussis
PO
Some gram neg, gram pos, SOME MRSA, some anaerobes,
Use if MRSA or e. coli known to be sensitive b/c cheap
Imipenem (Primaxin)
Ertapenem (Invanz)
Macrolides
Erythromycin
Azithromycin
Clarithromycin (Biaxin)
Tetracycline
atypicals - Kill some of everything
Relative CI in kids <8yo
Lyme, rickettsial, erlichiosis
Tetracyclines
Doxycycline
Glycylcyclines
Tigecycline RESTRICTED
IV/P
O
IV
Aminoglycosides
Gentamicin, tobramycin, amikacin
IV
Aerobic gram neg only, incl pseudomonas, no anaerobes,
only good at bloodstream pH, so no good in abscesses
Can do qday dosing
Quinolones
Ciprofloxacin
IV/P
O
G neg, most pseudomonas, atypicals, NO anaerobes
IV/P
O
Above plus G pos including PRSP, less pseudomonas
PRSP – pneumonia (with azithro inpt), sinusitis
Moxifloxacin
(Avelax)
Drug resistant gram pos/neg (acinetobacter, VRE), NO
pseudomonas
Highly oto/nephrotoxic. Gent – often used in r.o sepsis in
neonates, Amikacin/torbra – better nosocomial g- coverage,
tobra least nephrotoxic, best agains pseudomonas, nebs for
CF,
Levofloxacin (levaquin)
Lincosamide
Clindamycin (Cleocin)
IV/P
O
G pos, anaerobes, NO enterococc, will cover many
community acquired MRSA (not nosocomial), good tissue,
bone penetration, has antitoxin activity
Comm aquired MRSA, infxns involving toxin production
Metronidazone
Metronidazole (flagyl)
IV/P
O
Best for strict anaerobes
B. fragilis, C. dif
Sulfa
Trimethoprim/sulfamethoxazole (Bactrim)
IV/P
O
Many gram pos incl comm. aq MRSA, many gram neg, PCP,
no pseudomonas, no enterococcus
Cystits, PCP tx/prophy, COPD exac w/infxn
Polymyxin
Colistin RESTRICTED
IV
Very resistant G neg, no stenotrophomonas, causes renal
failure, periph neuropathy, CNS problems
When nothing else works for acinetobacter
Rifampin
Rifambin
G+ incl staph, g- incl pseudomonas, TB, NEVER alone except
for prophylazis, pregnancy category D
Adjunctively for bad staph infection, TB/meningitis
prophylazis
Monobactam
Aztreonam – RESTRICTED
IV
Only aerobic gram neg (just like aminoglycosides)
for severe pen allergies (can’t use piper or zosyn)
Glycopeptide
Vancomycin
IV/P
O
Gram pos, enterococci, IV – MRSA, MRSE, PO for c. dif,
resistant strep pneumo, not oto/nephrotoxic
Enterococc if pen allergic
C. diff resistant to metronidazole
Oxazolidinone
Linezolid (Zyvox)
IV/P
O
Gram +, enterococci, MRSA, MRSE, VRE
VRE
Linopeptide
Daptomycin (Cubicin) RESTRICTED
IV
Gram + (MRSA, VRE, MRSE)
VRE
YOUR GUIDE TO NAVIGATING THE OSUMC SYSTEM:
WebExchange: for text paging
RadWeb: Radiology
Essentris: used in the Ross, L&D, ICUs for vitals, labs etc
E-results:
Accessing Single Patient Data:
All Pt Search-Results > MRN or Name (MRN is quicker and precise) > pt name > Note the new set of tabs that come up to the left [Patient
Info, Clinical Summary, Medications, etc, etc….]. This method is best for looking up data for patients who are not currently
admitted/active in the hospital (i.e. they are incoming so you can get ready for them to come in…).
Accessing Patients on Your Service’s Census:
CapiWeb/Results >Service Census > click on your service’s tab (Ge2, Me1, etc)> click on the blue pt name/hyperlink for your desired
patient from the census that comes up> Note the new set of tabs that come up to the left [Patient Info, Rounds Report, Results, etc….].
On the first day, find out what your Service Census code is!
Setting your default Census (so that every time you hit the Service Census tab it will automatically bring up your service’s census.
CapiWeb/Results> Change Default Census> Select Service button > Hit your Service’s hyperlink and then the Enter button.
Finding Patients on Your Service’s Consult Census/Finding Your Service’s Consult Census:
CapiWeb/Results >Clinician Census >Physician Consult>Type the first letters of your service into the dialogue box (Surg, ENT, etc)> click
on your service’s hyperlink> click on the blue pt name/hyperlink for your desired patient from the census that comes up>
Getting Prepped for Rounds:
Printing out your Service’s Census: includes recent labs, meds and handoff note included for each patient (great to have on rounds)
CapiWeb/Results>Print for Multi Pts>Service Census>Click on the hyperlink for your service>select all (button at bottom)>Print for
Selected Patients>MD Rounds (Notes/ To Do/ PMH/ Labs): if you want one/page this is an option above the type of note you want
printed.
People like to add their daily info on these handouts to be ready to present during rounds.
Every morning you can just go to Rounds Report which will bring any notes, studies, labs, imaging that was done in the past 24 hrs.
H&Ps:
-
Results > Encounters > History and Physical: use this to see what has already happened with your patient. Sometimes the H&P is in the
Chart handwritten under H&P or Progress Notes.
To look at notes from the ED: Result > Encounters > Emergency so you can see what was done with the patient before they came in.
Consults:
Results > Encounters > Consultations OR look in the FRONT of the chart on yellow paper!
Labs:
-
Micro:
-
To get a full view go to Results > Last 5 occurrences, check all the tabs since they are listed under different things: hematology, body
fluids, chemistry etc
Results > Micro (back 90days) OR Micro(back 2.5 yrs). Make sure to check if it is Pending or the final read. Look at sensitivities.
Imaging:
Results > Radiology > occasionally find reports here (better to use RadWeb).
Use RADWEB program to look at imaging
Procedures: (Cath reports, EEG reports, EGD reports, Colonoscopy reports
Results > Procedures
if you want to see past reports that aren’t showing up click on the check box and then click view all.
Surgical/Pathology:
Results > Surg/Path
Current Orders:
Results>Display Current Orders > see all the medications they are on currently.
Can use this to see if the orders discussed on rounds were followed up on and put in.
You might also need to check Orders > View orders > then select pharmacy/lab etc to see if an order was placed > hit enter
Look at past discharge summaries if patients don’t know their medications: Results > Encounters > Discharge summaries
Under Documentation >Charted Med or MAR > click past # days you want > click display charted medications > enter: this shows you
what medications the patient was actually administered. Allows you to see if they are refusing medications or if one-time orders were
given. Also the place to see their insulin coverage if they are on carb coverage
In the CHART: Charts are in boxes outside the patient rooms the code is 2+4, then 3, turn, Or in the James at the nurses station.
Vitals:
- on a dedicated clipboard or in the chart (harder to find) under the Nurse Flowsheets tab.
- report ranges of vitals over the past 24 hrs. Make sure to divide up I/Os by type of Output
- look at the nurses notes on the back of the vitals sheet.
- All the ICUs, Ross heart, L&D: Use Essentris (another program with another password).
Consults: in the front on yellow sheets of paper
Progress notes: see follow up consult notes, PT/OT/Speech notes, progress notes for all services except medicine.
Paperwork from Outside hospitals: usually in the back of the chart or at the clerk’s desk.
Other Helpful Tips:
Writing Handoff Notes
Documentation>Notes> Enter/Revise Handoff Note (just write the pt’s one-liner and the major 3-5 parts of your management plan)
Writing Hospital Courses
Documentation>Arrival Meds/DI> Enter / Modify (under Discharge Instructions Heading) > Categories (at bottom of screen) > Check
Physician, Procedure, Hosp Course box and hit Enter button at bottom of screen
You MUST put in a dictating physician (type in the name of your resident, then search) or your hospital course will NOT save> then hit
enter—will take you to procedures
Procedures: type in pertinent procedures> enter;
Hospital Course: Summary is one liner: Course gives info about what you did for the patient.
Hit SAVE, NOT FINALIZE
Might be helpful to do it in your email and then enter daily b/c the formatting gets messed up.
Looking up that day’s OR schedule
CapiWeb/Results > OR Schedule-Campus or –UHE > Choose the proper date and sort by Surgeon, Room Number, etc. Also be sure to
select UH, James, or Ross Ors when looking for your case based on where it’s being performed that day (tabs at top of screen).