Hospitalist Service Guidelines 

1.      All H and P’s, daily progress notes and discharge summaries should follow thehospitalist format for those tasks (see below). 

2.      Interns are responsible for H & P’s up to the cap of five patients, progress notes on all non ICU patients and discharge summaries on all patients. Discharge summaries must be completed within 24 hours of discharge and a copy should be sent to the PCP and the consultants on the case. PCP’s expect a high quality discharge summary in the format we have outlined. If this is not done the discharge summary will need to be re-dictated.

3.      Residents are responsible for a RAN for each patient and progress notes on ICU patients. They should pre round with the interns and review all objective data on each patient from the previous 24 hours before the start of rounds. They should document a plan of care below each daily progress note on all patients before rounds. The intern should write all admit and discharge orders for their patients however the resident must review them prior to being turned in.

4.      When medical students (3rd or 4th year) write an H & P, the resident is responsible for writing or dictating a second H & P (rather than a RAN). Similarly, progress notes written by students must be followed by a full progress note written by the resident. Students may write a discharge summary but the resident must dictate the official discharge summary. 

5.      Residents and students should go to the bedside with the attending while making rounds. 

6.      Medication reconciliation should be addressed daily with particular emphasis on the day of admission and the day of discharge.

7.      All H and P’s done by medical students should be submitted to the attending. They should be reviewed and returned to the student prior to their next call with written or verbal feedback.

8.      Each resident, intern and student on the service should have components of the H & P supervised by the attending physician.

9.      The attending physician on call should be notified of all unexpected major changes in hospitalized patients. The on call attending should also be called about newly admitted ICU patients in whom there are diagnostic or therapeutic uncertainties.

10. Contact family members for any serious changes in a patient’s status.

11. Follow up all tests pending at discharge. Common examples of tests pending at discharge that can effect patient care are culture and sensitivity results, HIV tests, hepatitis serology and pathology results of biopsies.

12. At least one random H and P (or RAN) and one discharge summary from each resident should be reviewed in detail by the attending physician with verbal or written feedback.

13. Discharge orders should be either discussed or reviewed by the attending physician prior to discharge. The attending should insure that medicine reconciliation has occurred on discharged patients. Home medication changes should be limited as much as possible and any changes should be reviewed with the patient. Write a prescription for all medicines including OTC medications such as aspirin. Explain follow up care. This is all part of the physician’s job not the nurses.                                                                 

History and Physical

Chief Complaint

HPIThe HPI is a chronologicalaccount of the patient’s current illness including pertinent negatives and pertinent past medical and social history (HIV – CD4 count, heart failure – last documented EF, etc). Begin the HPI with “The patient was in his/her usual state of health until…”Make sure you give all details of the recent illness. Include information from old charts and family members.Pertinent positives from the Review of Systems if they pertain to the HPIRefrain from mentioning objective data (physical exam, labs, chest x-rays)

Past Medical History/Chart Review Past Surgical History Medications – include doses, frequency and over the counter and herbal meds! (i.e. Aspirin!)

Allergies and Adverse Reactions – include the type of reaction

Family History – first degree relatives

Social HistoryIncludes sexual history, living situation, travel, ETOH, drugs, tobacco, employment history

Review of systemsIf they relate to the HPI then state it there; everything else should be listed here; Remember that problems mentioned in the ROS belong on the problem list

Health Maintenance – vaccinations, cancer screening

Physical Exam

Vital signs – include pulse ox, BMI, orthostatic VS when applicable

HEENT – PERRL, EOMI, VA, fundi, TM, mouth, throatNeck – thyroid, carotid

Nodes

Cardiovascular – rate, rhythm, S3, S4, murmurs, PMI, JVP

Chest – palpation. Percussion, auscultation

Breast (when indicated i.e. breast sxs, possible cancer)

Abdomen – bowel sounds, bruits, tenderness, liver span. Masses

Back

G.U. (when indicated i.e. females with abdominal pain, GU sxs)

Rectal (when indicated i.e. GI bleeding, unexplained anemia, abdominal pain, high risk for impaction, prostate sxs)

Extremities - pulses, edema, clubbing

Skin

Neuro           Mental status       Motor      Sensory primary and cortical      Cerebellum      CN      Reflexes   

Labs(include pertinent old labs)      

Radiology (report old pertinent imaging {CT’s, echos, caths} here)

EKGs  (compare to prior EKGs when appropriate)

Problem list/PlanList problems in a prioritized manner. Include all abnormal data from the history, physical, and labs. Try to consolidate where possible. Have a plan for each problem and list them together. Example: Problem #1: Pneumonia with fever, chest pain, leukocytosis with left shift and abnormal CXR – blood/sputum cultures, avelox, legionella/pneumococcal urinary antigen etc.     

Progress Notes 

SOAP formatInclude all of the objective data new in the last 24 hours and note any tests that are pending. Write the vital signs in ranges of highs and lows. Include I’s/O’s and blood sugars when appropriate. Have an assessment and plan for each active problem. The last two problems should always include prophylaxis and disposition.Include all scheduled medications (dose and route) on the side of the note and make sure they are appropriate for the patient’s current condition; list antibiotic day number; include in this area IVF, central line day number and foley day number when applicable.  

Discharge Summary 

PCP

Date of Admit,

Date of Discharge

Discharge Diagnosis (include every diagnosis)

Consultants

Procedures

Brief HPI and initial presentation

Hospital Course – by diagnosis; discuss each active diagnosis chronologically (this is the essential part of the discharge summary)

Discharge Medications – list all meds including OTC’s and the dose and frequency. Remember that aspirin is a medication and needs to be listed if the patient is discharged on it. List discharge medications in the following manner:1.       Old medications to be continued at the same dose as prior to hospitalization2.       Old medications to be discontinued and why3.       New medications or new doses of old medications

Diet

Activity

Follow up

Studies Pending at Discharge(send a copy to the PCP and consultants on the case)