Additional Information for Subinterns
During your first week
 You should read the Primer to Subinternship on the first or second day of the rotation. This
primer was published by the CDIM. Some of the topics covered in the primer are how to: call
consultants, deliver bad news, discuss advanced directives, write transfer notes, and discharge
planning. While it is long (approximately 50 pages), it actually is very easy to read and should
not take more than an hour.
 Get a mask fit done (temporarily on hold)
 Get Maria and Dr. Novoa-Takara your days off schedule
Additional documentation responsibilities:
Subinterns will write comprehensive on and off service notes on assigned patients. These on and off
service notes will include a summary of the patient’s hospital course and a comprehensive problem list
and care plan. The on/off service note may be combined with the daily progress note.
Cross cover notes should be written when you see a patient at night.
Here is what I recommend you put in a cross cover note.
 Include 1-2 sentence background on the patient . Typically this is what their significant PMH is
and what they are admitted for this time around. This shows that you are aware of the major
medical problems.
 Document what you were called for. I would document the specifics because the nurses and
aids may accidently fail to document .
 Document your ROS and be specific—e.g. what is the pain level?
 Document a BRIEF physical exam . This should be situation specific, which would include vitals.
You might include cardiac, pulm, and abd as well.
 Document your differential diagnosis and keep it broad.
 Document your working diagnosis of the problem you were called on and how you will treat it
 Document response to treatment . You want to make sure that things are getting better or that
you are taking action if things are not getting better. Typically you will addend your original x
cover note for this, you should not wait to write the x cover note as things can get busy.
 When you have questions or if the patient is sick, be sure to give your senior resident a call
Students should prepare written discharge summaries on at least one of their patients during the
month and participate in the discharge process and arrange followup care for all their patients being
discharged. Your written discharge summary can be used by the resident. At the end of this, I will
include an example of a discharge summary that was done by the student and revised by the resident
that was used in the chart. You can copy that template in Word, write your discharge summary, and
paste it into the patient’s chart under document type discharge summary. If you or your resident need
help with this, please let me know.
Discharge Summary Template:
Introduction
Admission and discharge dates
Your name
Expected co-signer: Attending who discharge them with you
The patient’s full name
Medical record number
Diagnoses: For each one be specific (SIRS, sepsis, severe sepsis, septic shock, acute renal failure),
indicate ‘No complications, mild or major complications”, and if resolved, new or acute
exacerbation of a chronic problem. Example: acute or chronic blood loss anemia, severe
malnutrition
a. Principle diagnosis-reason for admission
b. Secondary diagnosis-complications and comorbid conditions (diabetes, htn, copd, etc)
Consultants-name and specialty (if you don’t have a name, list the group)
Operations/Procedures with BRIEF relevant findings (they also must be mentioned in your
hospital course)
History on presentation this should only be a couple of sentences about their initial
presentation. You might include the most significant parts of the physical exam/labs. DO NOT
include the entire admit H and P.
Hospital course by problem-a brief summary of each problem
Status at Discharge-Key PE (discharge weight, lab and/or medical imaging findings). Also good to
say what their functional status is (ambulates without assistances, bedbound, uses FWW).
Medications at Discharge: LIST ALL
a. Explicitly state all names, doses, frequency and quantity prescribed (if narcotics) AND
whether new, continues, or changed compared to pre-admission medications.
b. Home medications that have been discontinued
c. Vaccinations given
Follow up Arrangments :INCLUDE ALL OF THESE
 Name of physicians and appointment dates (if known)
 Pending test results to be follow up or other follow up tests needed. If there are none,
state, “none”
 Instructions on Diet and Fluids
 Instructions on Activity, wound Care or Other Limitations
 What to do if symptoms worsen/signs to look for
 Weight monitoring-when and what to do(if applicable—MUST be in heart failure and
should be in cirrhosis and some others)
 Smoking cessation instructions given for all people who smoked in the last 12 months
 CHF specific: document the EF (if outpt ECHO is planned, just state that), IF EF<40% AND
no ACEI or ARB prescribed, state the contraindication for both, weight monitoring
 Acute MI: document contraindication to beta blocker if not prescribed at d/c, IF EF<40%
state AND no ACEI or ARB prescribed, state the contraindication for both, document
contraindication to aspirin if not prescribed at d/c
 “If there are any questions, I can be reached at 602-839-5822”

Name of physicians who need a copy of report send, if outside local area please state
name and fax number
Teaching
Most of the teaching that occurs on this rotation will occur when issues arise or as patients present with
medical problems rather than through formal lectures. Students are expected to attend all grand
rounds and morning reports. Students will attend all subintern conferences. In the event of an
unavoidable absence students will be expected to independently review a standardized case of the
clinical scenario discussed that week.
Incidently, you are a teacher too. You can teach things to the third year student on your team. If your
third year student seems to be struggling (presenting, getting organized, etc), give them pointers.
Patient logs
The purpose of the log is to monitor each student’s experience and to channel them to see a broad
range of symptoms/diagnoses considered fundamental to inpatient medicine. These
diagnoses/conditions have been selected by the Clerkship Directors in Internal Medicine (CDIM) as
important inpatient competencies. These competencies (topics) are abdominal pain, acute
gastrointestinal bleed, acute pulmonary edema, acute renal failure, altered mental status, arrhythmias,
chest pain, drug withdrawal, electrolyte disorder, fever, glycemic control, hypertensive emergencies,
nausea and vomiting, pain management, respiratory distress, seizure, and shock. Try to see as many of
these specific diagnoses/symptoms (or as many as possible) during this rotation. Enter ALL patients you
have seen into the log. Information to be entered in the log includes patient initials and patient’s
diagnoses. Cross cover patients will also be entered but the only diagnosis that should be entered is the
one that the subintern was called to assess and manage
Each one of the above mentioned competencies (topic) has a patient based training problem created by
the CDIM. You may use the specific training problem for that topic to guide your study (see section of
subintern conference). You can discuss the specific topic with your resident/attending. Check off the
particular competency (topic) in your log once you have seen a patient with that symptom.
Case Presentation
Subinterns are expected to give one didactic presentation to their team and will be evaluated by their
attending physician.
Subintern Conference
Subintern conference will be held on a weekly basis. We will cover cases (see websites below) during
our sessions. You will be assigned prereading which should be completed before the conference. We
can also discuss problems and challenges that you are facing on your service. Do not do the case before
conference—we’ll walk through it.
Subinterns who are on nights that particular week are excused from subintern conference for case
discussions. However, they are still responsible for independently completing the on line case of the
topic discussed (e.g. GI bleed, Seizure, etc). Please contact the attending running subinternship
conference that week to let them know of your planned absence and to get the topic. NO STUDENTS
ARE EXCUSED FROM SIMULATION CONFERENCES. If you are on nights the week a simulation conference
is planned, you are expected to take the previous night off (take Wed night off if simulation conference
planned for Thursday afternoon and report for duty at 6 pm on Thursday). Please discuss with Dr. Novoa
if you are on nights the week simulation conference is planned and you have any questions. The cases
may be found at the following address:
http://www.im.org/toolbox/curriculum/CDIMsubinternshipCurriculum/Pages/TrainingProblemsStudent
Guide.aspx
Check your answers at:
http://www.im.org/toolbox/curriculum/CDIMsubinternshipCurriculum/Pages/TrainingProblemsTeacher'
sGuide.aspx
If the links or above addresses aren’t working, google Clerkship Directors in Internal Medicine and click
on Subinternship curriculum and training problems. Although it says you need a password for the
answers, you don’t.
Independent study
Reading on your patients is critical to your success. If you don’t get to see a particular diagnosis or
symptom from the list in the front of your booklet, you may also complete additional training problems
from the CDIM competencies. We tell our residents that they should be reading 108 minutes a day, you
should be doing that too.
Feedback/Evaluation
During the month, the student should have an attending evaluate (at least):
one history and physical
one progress note
one discharge summary (written)
one CEX/direct observation
one didactic presentation (presented to team on attending rounds)
It is helpful if you print a copy of the document (history/physical, progress note, discharge summary)
and give it to the attending for feedback. While only one formal evaluation of the above is required,
students are always encouraged to ask for more feedback. Your attending physician may delegate this
to the residents on your team. It is the student’s responsibility to give any specific paperwork required
by their particular school to the attending physician. Actively seek feedback from your team. Don’t
forget to turn in your log books at the end of the rotation and fill out and turn in your evaluation of
subinternship rotation.
Grading specifics
What you really want is for your resident or attending to be able to say,”I felt like _______(fill in your
name) was an intern!”
Here are the specific benchmarks I use for exceptional students:
 Medical Knowledge: Comprehensive knowledge of core learning problems.
 Understands pathophysiology, spectrum of disease severity, formulates broad differential
diagnoses, knows major and minor diagnostic studies, most treatment options and major and
minor complications of disease, studies, and treatments.
 Understands and can educate patients on indications and contraindications, risks, and benefits
of treatments and procedures.
Patient care:
 Able to reliably gather data and report accurately and efficiently to team through notes and oral
presentations.
 Able to independently and accurately interpret most clinical situations and test results. Able to
accurately recognize ill patients and changes in clinical situations.
 Able to independently formulate plans for diagnosis and treatment of most common
presentations and diseases.
 Able to appropriately obtain informed consent, coordinate care, address issues surrounding end
of life care.
Professionalism:
 demonstrates respect, compassion and integrity and demonstrates accountability and
excellence in carrying out responsibilities.
 Takes initiative in identifying and addressing needs of patient and team. Assumes responsibility
for own actions and monitors self for errors and areas to improve.
 Independently identifies and fills knowledge gaps. Is committed to excellence in patient care.

Is a patient advocate and works to address patient needs beyond basic medical care.
Interpersonal and communications skills:
 Excellent communication with the patient, family members with detailed attention to the
inclusion of relevant information and synthesis of clinical information, rationale for ongoing
treatment or new plans utilizing terms appropriate to patient’s educational level and scientific
jargon.
 Able to effectively communicate and establish rapport with even the most challenging patients,
nurses, and staff.
 Demonstrates understanding of the cultural sensitivities and patient wishes with regards to
health care and incorporates this knowledge into the discussions with the patient.
Practice Based Learning and Improvement/Life Long Learning:
 effectively assimilates and appraises clinical information and evidence and uses it effectively to
improve patient care.
 Not only recognizes what to do for best outcomes, but also why, based on what literature and
who says.
System based Practice/Social and Community Context of Care:
 Demonstrates proficiency in coordinating comprehensive and longitudinal patient care both
within the hospital and during transition of care from inpatient to outpatient settings.
 Demonstrates understanding and coordinates patient care plans utilizing the resources
available both in the hospital and in the community in an appropriate and efficient manner.
Issues of concern
For serious concerns that you want to anonymously report, please use our “Issues of Concern” reporting
at the goodsamim.com website. Click on “Issues of Concern” on the left bottom of the screen.
Applications for Residency at Banner Good Samaritan
Please notify Connie Farrington once your ERAS is uploaded. Students should schedule an appointment
with Dr. Cheryl O’Malley or Dr. Kerilyn Gwisdalla. Schedule the appointment with Dr. O’Malley through
Connie Farrington in medical education 602-839-3644 or connie.farrington@bannerhealth.com. To
schedule with Dr. Gwisdalla, please email her (Kerilyn.Gwisdalla@bannerhealth.com). Med/peds
candidates should contact Dr. Donna Holland (dholland@phoenixchildrens.com). Preliminary internship
candidates should contact Dr. Brenda Shinar (Brenda.shinar@bannerhealth.com).
If you have any questions or concerns, contact Dolores Castro (Dolores.Castro@bannerhealth.com
(preferred) or phone 602-839-5961) or Dr. Novoa-Takara (kendall.novoatakara@bannerhealth.com or
pager 201-0921).
DISCHARGE SUMMARY TEMPLATE/SAMPLE:
INTRODUCTION:
a.
Pt’s full name (spell):
b.
MRN / FIN:
c. Admission Date and D/C date:
d.
Expected Co-Signer:
e.
Date of Birth:
DISCHARGE DIAGNOSES:
Principle Diagnoses
1) Profound microcytic anemia with hgb down to 4.1
2) Reported UGI Bleed by pt history with no objective
evidence of such
3) Positive Hepatitis C Antibody Screen
4) Evidence of cirrhosis on abdominal imaging with
thrombocytopenia and coagulopathy
Secondary Diagnoses
1) History of ETOH consumption to excess
2) History of Hepatitis A exposure
CONSULTANTS:
1) Gastroenterology
IMAGING:
1) 4/6 – CXR with no acute pathology
2) 4/8 – RUQ US nodular and mildly heterogeneous ecogenicity
compatible with hepatic steatosis and/or chronic changes
of hepatocellular disease, commonly chronic hepatitis
infection and/or cirrhosis. No focal intrahepatic
lesions seen. CBD 8mm. Cholelithiasis and Gallbladder
sludge. Mild ascites.
OPERATIONS / PROCEDURES:
1) 4/7 – Upper endoscopy – no source of bleeding and no
evidence of recent bleed.
2) 4/9 – Colonoscopy – 2mm hepatic flexure polyp removed.
Fair Prep. No evidence of bleeding. Moderate Internal
Hemorroids.
PRESENTING HISTORY:
44 yo latino man who came in yesterday complaining of 3 episodes
of emesis colored like coffee. He also had diarrhea the day
before and that had some blood in in it. Notably, pt was found
to have a hgb 4.1 with mcv 69, rdw 22, plt75 and an INR 1.5 on
admission. VS were HR 101, bp 107/54. Pt denies heavy ETOH
use, and then admits he over did it this past weekend. GI
fellow’s exam showed no evidence of bleeding on rectal exam.
HOSPITAL COURSE:
He received 4u RBCs, 4u FFP and 1 unit platelets on day of
admission. An EGD on HD 2 showed no source of bleeding and no
evidence of having been bleeding. He was cleared for conversion
to PO ppi and advance diet as tolerated and to leave the ICU.
Pt was here 2 years ago (under MRN: xxxx) with a similar
complaint but a hgb only as low as 7.1 (plt 66, INR 1.6) and the
upper endoscopy was also not revealing.
Given the history of profound anemia and also a nonspecific
complaint of bloody diarrhea, we performed a prep and a
colonoscopy. Findings outlined above, final path pending.
Following up on the Cirrhosis suggested by the abdominal
ultrasound and abnormal labs, we checked Hep serologies. Hep A
Total Ab was (+). Hep B SAb, SAg, Core Ab total and Core IgM
were all (-). Hep C screen was (+). (Now reviewing the other
chart, it was also positive in 2011).
Given the “gi bleed” and cirrhosis with ascites, we started
ceftriaxone 1g iv qday for SBP prophylaxis. Pt will go out on
ciprofloxacin to complete 7 day course of antibiotics.
Endoscopy revealed no esophageal varices so betablocker is not
indicated. He does not need to be on long term sbp prophylaxis.
STATUS AT DISCHARGE:
regular diet.
NO signs of active bleeding.
MEDICATIONS AT DISCHARGE:
* NEW Medications
1) Ciprofloxacin 500 mg po bid x4 more days
Tolerating a
* DISCONTINUED Meds
1) NONE
* CHANGED Meds
1) NONE
* CONTINUED Meds:
1) NONE
DISCHARGE INSTRUCTIONS:
DIET:
ACTIVITY:
Regular Diet
As tolerated
FOLLOW UP:
Call one of these two clinics and find out where you can go to
find a doctor.
Mountain Park Health Care
602-243-7277
OR
Wesley Community & Health Center
1300 South 10th Street
Phoenix, AZ 85034
602-257-4338
Mo-Th 8am-9pm
Fr
8am-5pm
Get a CBC (blood count)and Iron Studeis in
1 month (approximately May 7th, 2013)
For Patient:
1) You need to establish care with a primary care physician two
clinics listed above.
2) You need to get blood tests done in 1 month after leaving the
hospital (listed above).
3) You had very bad anemia when you came in (hemoglobin of 4.1)
4) You are positive for the Hepatitis C screening test. This
means you have a high likelyhood of having chronic hepatitis C
infection. We won't be 100% sure until we get the hepatitis c
viral load results back in 1 week.
5) You got the first dose of Hepatitis B Vaccine today.
You need to get a 2nd dose in 1 month (mid may), and a third
dose after 6 months
(End of October, 2013).
6) You have cirrhosis of the liver based on ultrasound, Platlet
count and INR.
7) You had a normal upper endoscopy
8) You had a nearly normal colonoscopy. A very small 2 mm polyp
was removed and will be examined by the pathologist. Depending
on what the result is, you may need to get another colonoscopy
in 1, 3, 5 or 10 years.
9) In about 2 weeks after leaving the hospital, your doctor can
call for and get the answers to the following Pending tests
(Listed below).
PENDING TEST RESULTS
polyp
- Final pathology: Hepatic flexure colonic
Hep C – Viral Load
A copy of this discharge document was given to the patient so
that he can take it with himself to all follow-up appointments.
Any questions can be directed to us at the following number:
602-839-5822 .
Signed,
Xxxxx xxxxxx, MD – R3 Internal Medicine Resident
Kendall Novoa-Takara, MD – Attending Physician
Residents will keep an eye out for the results of Pending tests
and communicate them to the patient.
PS: Review of the chart this afternoon after the patient had
already left revealed that he was H Pylori (+) on his gastric
biopsy. Will need to contact him and advise him to get
erradication therapy and that his H Pylori blood test will be
positive life long.
PS: Colon polyp path came back as tubular adenoma.
next colonoscoyp in 5 years. (March 2018).
Pt due for