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Daily life of the intern

Last updated: April 29, 2021

Summarytoggle arrow icon

Congratulations on moving on to the next stage in your professional career! This article is part of a series called "Transitioning to residency," which is designed to help new interns and subinterns adjust to their new responsibilities. The other articles in this series include:

This article focuses on how to organize your day, prioritize tasks/patients, document the care you provide, transfer/coordinate care of your patients, and navigate night float and call shifts.

The following is an example of a typical daily schedule of a resident on a medical inpatient ward-based service. Daily tasks and duties can vary significantly for residents working in emergency departments, surgical services (e.g., OR, recovery room), psychiatric wards, outpatient clinics, imaging or laboratory departments, critical care units, and other patient care settings.

Sample daily schedule for residents on a medical inpatient ward
Time of day Task Tips and tricks
Morning
  • Check on sickest patients.
  • Examine sick patients and patients that had significant overnight events first.
  • Perform the chart review outside their room.
  • Introduce yourself to the patient and their nurse.
  • Preround
    • Chart review
    • Examine your patients.
  • Round on patients in a logical order (e.g., first the sickest patients, then patients of residents leaving postcall or for clinic, then discharges, then the rest of the service).
  • Devote more time to new admissions.
  • Assign team roles during rounds.
  • Make sure any urgent issues are addressed before leaving for the noon conference.
Lunch
  • Eat.
  • Protected educational time
  • Make time for lunch.
  • Eat during your protected educational time.
  • Assign a designated pager person during conferences.
Afternoon
  • Check your to-do list.
  • Make sure all action items have been done.
    • Call consults if they were not already called during rounds.
    • Place orders.
    • Complete discharges.
  • Update patient problem lists.
  • Some teams review the list again in the afternoon to follow up on to-do items and provide updates.
  • Finish notes.
  • Admission notes (H&Ps) that were not completed during the night shift
  • Progress notes
  • Discharge summaries. Finish them on the day of discharge.
  • Pick up new admissions, if applicable.
  • Know your hospital system.
    • Rotating admission teams
    • Spread out admissions.
  • Remember the patient comes first.
    • See the patient.
    • Write the orders.
    • Leave a brief note with the background, assessment, and plan.
    • Write the full H&P later, when you have time.
End of day
  • Wrap up loose ends from your to-do list before signing out.
  • Dedicate time to update the written signout list.
  • IPASS signout

One of the biggest challenges during the transition from medical student to intern is adjusting to the change in roles and responsibilities. While a medical student's primary role is to learn, a resident's primary responsibility is patient care, which involves completing numerous tasks throughout the day . These tasks and responsibilities can seem overwhelming at times, but they can be managed effectively by establishing a system.

Develop a system

An efficient system is one that becomes second nature; you perform the same steps in the same order each time. This reduces variability and decreases the chance of forgetting something.

Organization

  • Lists: should make your work faster (rather than create more work)
    • Team patient list
      • Typically printed from the EMR and used for rounds
      • Provides necessary information related to each patient (e.g., room number, date of birth, medical record number, background information)
      • Can be used to jot down important information needed before/during rounds (e.g., examination findings, relevant laboratory results, to-do items)
    • Signout list
      • Can be printed from the EMR and should be utilized during every signout
      • Typically used for night/on-call shifts
      • See “IPASS.”
    • Checklists
      • Used in many ways as a reminder for important tasks [1][2]
      • Can be written on the back of the team patient list or completed on a separate paper or template
  • Centralize important information: provides quicker access to the information you need
  • Prioritization: Know what to do first.
    • Patients: Sicker patients need to be seen and addressed first.
    • Rounds: Begin with sick patients, then see any leaving residents' patients , and finally the rest of the service.
    • Tasks
      • Do time-sensitive tasks first (e.g., consults, ordering labs/tasks that are needed that day, finishing notes).
      • Do non-urgent tasks later in the day (e.g., ordering laboratories or imaging studies to be done the following day).

Delegation of tasks

  • Assign team roles when rounding so it is clear who is responsible for each task (see “Rounds in residency”).
  • Allow medical students, especially subinterns, to help with tasks; E.g., calling physician offices to obtain records, notifying a nurse when an urgent order has been placed, writing notes you can then edit.

Electronic medical record (EMR) tips

Think of things you do multiple times per day and find ways the EMR can facilitate these tasks.

Customization

  • Dot phrases or shortcuts can be used to:
    • Place common clinical scores into a table where positive findings can be highlighted/bolded quickly in the chart
    • Sign with date and time stamp (if the EMR does not immediately sign for you)
    • Reference team and/or personal contact information quickly
    • Document event notes quickly
      • General notes that can be tailored to the event
      • Custom notes for common clinical events like respiratory distress, asthma, chest pain, or ER reassessment notes
  • Order sets
    • Orders that commonly go together are bundled into an order set.
    • Admission orders
      • Mnemonics can be used (although they might be cumbersome), for example:
        • AD CAVA DIMPLS
        • ADC VANDALISM
      • Many hospital EMRs utilize order sets that include the key components for general admission and also for common diagnoses.
  • Note templates serve as a checklist for important information to include in notes.
    • Templates may exist for different types of notes.
    • The same type of note may have different templates depending on the condition.
    • You can star frequently used note templates in your EMR or record them in the resident reference sheet
  • Patient lists
    • The columns in a patient list include information you need at a glance, e.g., patient name, DOB, medical record number, HPI
    • Patient lists can be copied to a personal list that you can modify without affecting the team list; Adjust the columns according to your preferences.
      • Add additional information you need.
      • Order the columns in a meaningful way.
      • Delete information you do not need.
  • Time stamp your patient list.

Non-clinical EMR use

  • EMRs often have sections that are not official parts of the patient's chart. These are sometimes called “sticky notes” or communication sections
  • You can utilize these sections for communication and signout.
    • Communication: Enter your team contact information dot phrase for nurses and consulting services to access quickly.
    • Signout: Enter a signout dot phrase (e.g., lPASS template) for each patient that can be printed in a report with the team list and serve as a standardized written signout.

The following guidance pertains to the rounds encountered on a typical medical inpatient ward-based service. Rounds, patient presentations, and team roles can vary for residents working in different medical specialties, on different services, and even between different attendings on the same medical service.

Styles of inpatient rounds

Understand the pros and cons of different styles of rounding. Patient-centered communication is essential to respect patient autonomy and shared decision-making. It also enhances patient understanding and trust in the healthcare team, which are linked to better patient outcomes. [3]

Benefits and disadvantages of different rounding methods
Styles of rounds Benefits Disadvantages
Table rounds
  • The team can agree upon a plan before updating the patient
  • Teaching can occur away from the patient.
  • Faster
  • Fewer distractions
  • Best for patient privacy
  • The physical examination cannot be verified by the attending until later.
  • Patients are not actively involved in medical decisions.
Hallway rounds
  • The team can agree upon a plan before updating the patient
  • Teaching can occur away from the patient.
  • The physical examination occurs immediately after medical discussions on the patient.
  • May include the patient's nurse
  • Potential for HIPAA privacy breaches
  • Patients are not actively involved in medical decisions.
Bedside rounds (e.g., patient-centered and family-centered rounds)
  • Patients are included in the discussion and can:
    • Ask questions
    • Correct mistakes and clarify the presentation/history
    • Participate in decision-making
  • Fosters better physician-patient communication
  • May include the patient's nurse
  • More time consuming
  • Can be difficult to teach in front of patients.
  • Potential for HIPAA privacy breaches
  • Cannot bring computers into infection precaution rooms.

No matter what style of rounds is used on a service, it is preferable to make room for and prioritize time spent at the bedside as much as possible. Administrative duties and learning are important and can seem overwhelming at times, but remember that the main beneficiaries of your work are the human beings whose health and lives are directly impacted by your care.

Teamwork

  • Team roles: Roles should be defined before each patient is discussed.
    • Presenter: the intern/resident assigned to the patient
      • Ideally, they will be presenting from memory, with brief notes.
      • Follow the SOAP note format. See “Daily progress note” for further information.
      • Write down to-do items after your presentation is complete.
    • Computer person
      • Place computer orders.
      • Access relevant information from the EMR, e.g., laboratory results, notes, and vitals.
      • May write down action items for the primary resident's to-do list.
    • Phone person
      • Call consults in straightforward situations.
      • Answer phone calls and pages.
  • Benefits of team roles
    • Efficient: prevents delays in patient care by allowing orders to be placed during rounds
    • Responsibility: When roles are defined, there is less chance of something being missed.
    • Courteous: Consulting services appreciate earlier consults.
    • Less distracting: Minimizes distractions from pagers and phone calls
  • Closed-loop communication
    • The presenter should touch base with the attending after each patient to verify the plan.
    • All roles (including the nurse) should communicate what was done and what still needs to be done for each patient.
    • Update each patient and their nurse on changes/updates to their treatment plan as soon as possible.
    • See also “Communicating with nonphysician team members” in “Communication during Residency.”

Patient presentations

General tips

  • Presenting for the benefit of the team
    • Start with a one-liner to remind everybody of the patient's name and reason for admission.
    • Present in the same order as your progress note (SOAP format), highlighting positive and pertinent negative findings.
    • Try to present from memory, with only quick references to your list.
    • Avoid getting buried in details.
  • Presenting for the benefit of patients and their families
    • The expectations and responsibilities surrounding patient communication are higher in residency than during clerkship.
    • Effective and respectful communication with patients can often be challenging, e.g., due to time constraints, administrative requirements, competing needs of other patients, stress levels of patients and health providers.
    • Make the best use of time at the bedside
    • Recall foundational concepts in patient communication and counseling.
    • See “Communicating with patients” in “Communication during residency” for introductory guidance on styles and techniques.

Key differences between residency and clerkship

Medical students typically focus on collecting information and considering possible diagnoses (see “Clerkship guide”). Residents must build on these skills by detailing their thought processes and justifying their next steps, and also systematically communicate their overall impression and management plan for each patient. The following aspects should be emphasized and refined when presenting patients as a resident:

  • Reporting results
    • Recall the specific purpose of any labs, procedures, examination findings, and consults obtained for the patient.
    • Do not just report values and studies; provide your interpretation of the underlying process and how it might impact patient care. This sets the stage for your assessment and plan section.
  • Formulating an assessment: includes the working diagnosis, differential diagnosis, and/or problem list.
    • Identify any severe or critical conditions in the differential diagnosis, and indicate if and how these have been ruled out.
    • Provide an estimate of the certainty surrounding the working diagnosis.
      • If uncertain, suggest a plan to narrow the diagnosis.
      • If certain, emphasize or summarize data that justify this conclusion.
      • Include any responses to initial treatment received prior to your assessment.
    • Prioritize the patient's clinical problems by order of importance.
      • Present the problems with the highest risk of mortality and morbidity first.
      • Specify problems that correspond to the patients' chief concerns as well as those unexpectedly identified during their workup.
      • Identify any problems requiring time-sensitive investigations and/or management.
  • Proposing management plans
    • Indicate the standard treatment plan for any newly identified clinical problem.
    • Include any deviations from standard care and reasoning behind these.
    • Summarize treatment and medications that have been administered.
    • Include assessments of responses to treatment and progression of the illness.
    • Suggest any necessary modifications to existing care plans and next steps.
  • Considering disposition and discharge planning
    • Identify any management steps that could require an alternate level of care.
    • Monitor progress on clinical problems that necessitate ongoing hospitalization.
    • Identify the discharge goals and whether the patient meets any existing discharge criteria.
    • Indicate any potential barriers to safe discharge.
  • Learning
    • Address information that does not make sense with either your senior resident or attending after your presentation.
    • Focus on learning from your attending and fellow residents rather than trying to impress others.
    • Incorporate feedback with an open mind.
      • Do not get defensive or insecure when an attending asks you a question; consider it a learning opportunity.
      • Questioning by a senior is often used to guide your thought process or to make you think of possible alternatives in the future.
    • Mistakes are among the strongest drivers of self-directed learning and improvement; keep track of topics to read up on later.

Planning effective discussions with patients

  • Laying the groundwork
    • Let patients and families know who the primary team members are and the hours they are in the hospital.
    • Give a time frame for when rounds occur so they can make plans to be there if possible.
    • State other ways that family members can attend rounds if they are unable to be there in person.
  • Soliciting patient input
    • Ask patients directly about their symptoms and progress unless they indicate otherwise.
    • Do not rely purely on computer-generated data or second-hand information.
    • Address their most pressing queries and concerns.
      • If you do not know the answer, propose a plan and estimated time frame to find one out.
      • If the patient has more questions than you have time to answer, ask to write them down and revisit them at the next available encounter.
  • Updating patients, family members, and caregivers: Do not expect nursing staff to bear sole responsibility for this.
    • Explain the following to patients whenever possible:
      • Patient data: e.g., working diagnoses, test results, care plans, prognosis
      • Reasoning, risks, and benefits: e.g., for examinations, tests, procedures, consultations, disposition
      • Logistics: time-frames, sequence of care, frequency of monitoring, reasons for delays
    • Decide the optimal moment to provide the update: e.g., during rounds, once results are available, or when there are changes to the plan
    • Types of updates
      • Updating the patient in person
      • Calling the patient's room
      • Calling family members (with permission)
    • Anticipate/recognize when more lengthy or difficult conversations are required and allot more time for them.
  • Managing difficult situations in communication: e.g., broaching unpleasant topics, handling conflicts
    • Understand that these challenges can arise despite optimal communication techniques and preparation.
    • If they occur, it is often worth tackling them with extra time and attention, even if they disrupt the daily routine and cause stress.
    • Seek help from your seniors and attendings to support you, adapt your approach and avoid delays in the care of other patients.
    • Examples

This can be one of the most stressful tasks in patient care for new residents. Look up recommended orders and medication doses prior to entering them if unsure. Do not hesitate to ask for supervision and advice from senior residents, attendings, or pharmacists, especially at the beginning of intern year.

  • Responsibilities
    • Orders you enter into the EMR can be carried out without being checked by a senior resident or attending; doublechecking is preferable to making an error.
    • You are responsible for ensuring that orders have been completed for patients under your care.
      • Consider also verbally communicating critical or time-sensitive orders with the nurse or allied health professional.
      • Follow up on and troubleshoot any unexpected delays in investigations or treatments ordered.
    • You may be responsible for co-signing orders written by medical students on your team.
  • Order protocols
    • Follow your local EMR protocol for order sets and prescribing policies.
    • Consider asking a colleague to walk you through a new EMR if you have not received formal training in order entry.
    • Schedule serial orders for times that are least disruptive to patients and staff.
    • Special medications
      • Some medications may require special permission to release (e.g., from a specialty service or pharmacist).
      • Inquire about the local protocol to enter custom or nonformulary medications.
  • Reevaluation of existing orders
    • Remember to perform a medication reconciliation upon admission, at transfers of care , and prior to discharge.
    • Review the need for serial investigations, e.g., consider discontinuing daily CBC and BMP when these are no longer necessary.
    • Do not assume orders prescribed in other care settings (e.g., ER, ICU, recovery room) will be continued on the ward.
  • More information

Disclaimers

  • The examples provided are those of common notes used in a medical inpatient ward-based service. Notes can vary based on the resident's specialty and location of department/service.
  • Our guidance and examples serve as educational material and are not meant to be interpreted as medical advice or to replace local policies or standard operating procedures regarding documentation.
  • Consult your local hospital and state policies, or ask senior residents and/or attendings about specialty-specific standards of practice and preferences for charting.

Writing patient notes

Key differences between residency and clerkship

  • The emphasis on interpretation, reasoning, assessments, and plans recommended for patient presentations should also be reflected in the patient notes.
  • Support any assertions and considerations surrounding working diagnoses, differential diagnoses, and care plans with objective patient data.
  • Consult local hospital and state protocols, senior residents, and attending staff about elements of documentation required for medicolegal and administrative purposes.
  • Consider a “problem list” approach to document multiple assessments and plans that might be independent of each other in a single patient. For example, patients with:
    • Multiple undifferentiated clinical problems that each merit their own workup
    • A mixture of differentiated and undifferentiated problems
    • Multiple concurrent conditions that each require specific management

Note characteristics

  • Accurate
    • Do not copy and paste entire notes.
      • Multiple inaccuracies can occur, e.g., dates that are not updated (antibiotic day, culture results, postoperative day) and/or old information that is not deleted.
      • If there is too much information, the most relevant facts will be harder to find.
    • If something in a submitted note needs to be corrected or there was a change in plan, place an updated addendum at the bottom of the note. Do not alter the original note.
  • Relevant
    • Be concise.
    • Use templates (see “EMR tips”) as a checklist to include relevant information.
    • Think about what someone on the following shift, next rotation, or a consultant will need to know.
      • Summarize why the working diagnosis was considered over another potential differential diagnosis, especially in patients with atypical presentation.
      • Include what diagnoses are still under consideration for as yet undifferentiated clinical problems.
  • Understandable
    • Avoid any abbreviations with the potential for ambiguity.
      • See “Tips and links” for the Joint Commission's Official “Do Not Use” List of abbreviations.
      • Every accredited hospital is required to have an approved list of abbreviations.
    • Read through your note before you submit it. Does it make sense?
  • Timely: Notes are only helpful if they are available when someone needs the information.

Emphasize information that will be useful for colleagues consulting or taking over your patients' care, i.e., your reasoning, assessment, and plan. Use techniques that minimize communication errors and maximize patient safety. Make sure to adhere to administrative and medicolegal requirements, and use language that is accurate, professional, and respectful to patients.

Types of notes

  • Admission note (H&P)
    • Includes a thorough medical history
    • Lists treatments up to the point of admission
    • Identifies the reason for admission
    • Proposes a plan for hospitalization
    • Includes contact information for the patient's primary care physician (PCP), pharmacy, and a family member/friend
  • Daily progress notes
    • Only includes information relevant to the day's decision-making. It should not be a running hospital summary.
    • See “Daily progress note” for further information.
  • Discharge summaries
    • Summarizes the patient's hospital care
    • Provides patient instructions
    • Transfers care and communicates action items to the patient's primary physician
  • Transfer notes
    • Written by the service transferring the patient from their care
      • Summarizes hospital course, including the reason for transfer (see “Summary notes.”)
      • Provides important follow-up action items
    • Needed when a patient:
      • Moves between levels of care
      • Moves to a different service
  • Floor accept note
    • Written by the service accepting a patient onto their service from another service
      • Acknowledge reviewing the patient's chart, hospital course, and transfer note.
      • Document a physical examination.
      • Include your assessment and plan now that the patient is under your care.
    • Needed when a patient:
      • Moves from a higher level of care to a lower level of care
      • Returns to the floor after a procedure/surgery/imaging requiring sedation
  • Event notes: Any action/order/intervention that occurs and is not included in the daily progress note needs to be documented in the chart.
    • SOAR plan for events that require a bedside evaluation: See “Event note examples.”
    • Provide updates on any actions you take, even if a physical assessment is not required.
  • Summary notes
    • Think of this as a discharge summary in progress.
    • Needed in the following situations:
      • Patients with prolonged hospital stays
      • For ward patients: at least weekly
      • For ICU patients: more frequently (e.g., every 2–3 days)
      • Any patient hospitalized longer than 2–3 days when a resident rotates off service

One of the most common standardized formats for daily progress notes on inpatient medical wards is the SOAP format. The way daily progress notes are documented can vary significantly for residents in different hospitals, specialties, departments, and may be dependent on the attending physician's preferences. All progress notes typically contain the following information even if the format differs.

SOAP format

Your SOAP notes as a resident should be more focused and concise than what is typically expected of medical students. The most relevant components include the following:

  • Notable events: significant occurrences in the past 24 hours
    • Notable overnight events
    • Trends in relevant information compared to the preceding 24 hours, if applicable (e.g., number of PRN pain medication doses, amount of oxygen flow needed)
    • Responses to interventions from the prior day’s plan
  • Subjective
    • How does the patient feel?
    • Any change in symptoms or development of new symptoms?
  • Objective
  • Assessment: Summarize your thoughts regarding the patient as succinctly as possible.
    • Discuss differential diagnoses.
    • State only the relevant history.
    • Address the active problems that are keeping the patient in the hospital.
    • State overall impression: improving, not improving, worsening
  • Plan
    • Interventions you are continuing, discontinuing, or adding
    • Discharge goals

Daily progress note example

Patient name: John Doe, Jr., DOB: 1/1/1961

Date of admission: 1/1/2001

Notable events: Last night at 22:30 the patient experienced respiratory distress and wheezing. He responded well to 8 puffs of albuterol via MDI. The frequency of MDI treatments was changed from q3 hours to q2 hours per RT assessments. This morning, treatments were spaced back out to every 3 hours and he has been weaned to room air since 02:00 today.

Subjective: Mr. Doe reports significant improvement in shortness of breath and chest tightness today. Cough and appetite have both improved. No new symptoms to report.

Objective

  • Vitals: reviewed over the past 24 hours; notable for O2 saturations 94–96% on room air, and RR 14–26 (elevated during his episode of respiratory distress). Afebrile. Good I&Os.
  • Physical exam (examined at 06:30- 2.5 hours after last albuterol MDI)
    • Gen- Well-nourished, overweight male, in no apparent distress, sitting up and able to complete full sentences when answering questions.
    • HEENT- Nasal cannula has been removed, no nasal flaring.
    • CV- RRR, no murmurs/rubs/gallops, cap refill normal < 2 seconds.
    • Resp- Improved air entry bilaterally compared to yesterday, especially at the lung bases. Faint scattered end-expiratory wheezes. No crackles. No retractions or accessory muscle use.
    • Abdomen- Soft, NTND, positive bowel sounds.

Laboratories

  • No new results in past 24 hours
  • Blood cultures still negative at 48 hours

Imaging

  • No new in past 24 hours

Assessment: John Doe, Jr. is a 60-year-old male with 3 asthma-related ER visits in the past 9 months who was admitted for acute exacerbation of asthma with a new oxygen requirement. CXR upon admission was negative for pneumonia. He has responded well to frequent albuterol treatments and has been spaced out to every 3 hours and weaned to room air.

Plan

Signature

Thor Odinson, MD 1/3/2021, 06:34

PGY-1 Resident

Discharge summaries will often differ based on the medical specialty, the department, the attending, and hospital policy. Please consult the appropriate individuals to ensure you are following your local policies.

General rules

  • Summarize the hospital course in a way that makes sense.
    • Chronological: If the hospitalization was relatively straightforward, a paragraph or two that summarizes the hospital stay is usually sufficient.
    • Problem-based sections that are each chronological: If the patient had many different issues being addressed, give each issue its own paragraph and summarize the treatment for each issue chronologically.
    • Focus on elements of the course that affected patient outcomes and management steps.
  • Keep it relevant. Examples of low-yield information that can likely be left out include:
    • Daily updates: E.g. how often a patient received albuterol each day or how much oxygen a patient was on each day
    • Routine medications: E.g., saline flushes , acetaminophen for fevers
    • Minor procedures: E.g., IV placement
  • Make sure any EMR autopopulated information is easily readable. You should be able to look at the summary and easily find the information of interest.
  • Check for accuracy, verifying the following:
    • The admitting and discharge physicians are correct.
    • The PCP listed is the one the patient actually sees.
  • Discharge summaries should be completed on the day of discharge. Give one copy to the patient at the time of discharge and send another copy to the patient's primary care provider.

Key elements of a discharge summary

The following are the minimum components mandated by the 2008 standards of The Joint Commission and the 2009 Transitions of Care Consensus Policy Statement: [4][5]

  • Admitting information
    • Admitting attending physician
    • Primary care physician
    • Diagnosis on admission
    • Other diagnoses addressed during hospitalization (problem list)
  • Discharge information
    • Physician
    • Diagnosis upon discharge
  • Hospital course: Summary of the hospitalization
    • Reason for hospitalization
      • Include the chief concern.
      • Summarize the HPI.
      • Summarize care provided in the ER.
    • Important results of investigations
    • Treatments provided
      • How the patient responded to therapy
      • Any deviations from standard treatment or major complications
      • Consults and their recommendations
      • Procedures
  • Relevant data
    • Laboratory, microbiology, pathology studies; summarize trends and report the most recent results.
    • Imaging reports
  • Final consultant recommendations (listed out)
    • Discharge instructions from the consultant
    • Contact information for the consulting service
    • Don’t forget consults from allied health professions.
  • Discharge condition
    • Overall statement on the patient’s health and cognitive status
    • A focused physical examination may help provide a comparison for the primary care physician at follow-up.
  • Patient instructions
    • Include restrictions: e.g., driving restrictions, activity restrictions, swallowing precautions
    • Equipment: e.g, walker, crutches, oxygen, wheelchair
    • Follow-up appointments
    • Diet
    • Wound care
    • Red flags and return precautions
    • Medications, e.g., include any changes and underlying reasoning
    • Include allergies, especially if new allergies were diagnosed during the hospital stay.
  • PCP instructions
    • Pending labs/tests
    • Orders/actions for follow-up
  • Attending physician signature: also provide contact information

Example discharge summary

Patient Name: Jonathan Storm

DOB: 12/20/1950

Admission date: January 3, 2021

Admitting physician: Dr. Steve Rogers

Admitting diagnosis: pneumonia

Problem List

Discharge date: January 14, 2021

Discharge physician: Dr. Natasha Romanova

Discharge diagnosis

  1. Pneumonia due to Streptococcus pneumoniae
  2. Pneumonia due to MRSA
  3. Non-small cell lung carcinoma

Hospital course

Jonathan Storm is a 70-year-old former smoker who presented to the ER on 1/3/2021 with 10 days of cough, shortness of breath, fatigue, and new fever to 104°F. In the ER he was in moderate respiratory distress, had crackles in the RML, and CXR confirmed a RML pneumonia. He was started on 4L O2 via NC, given IV ceftriaxone and PO azithromycin, and admitted to the floor for further management of RML community-acquired pneumonia (CAP).

He continued to spike high fevers despite 4 days of IV antibiotics and broadened antibiotic coverage with vancomycin/ceftriaxone. Pulmonary medicine was consulted on 1/7/2021; they recommended switching antibiotics to linezolid plus piperacillin-tazobactam and obtaining a chest CT, which showed a right hilar mass with almost complete obstruction of the right mainstem bronchus. On 1/8/2021 the Pulmonary service performed a bronchoscopy, biopsied the identified endobronchial mass, performed tumor debulking with stent placement, and obtained a BAL. BAL cultures later grew MRSA and S. pneumoniae. Pathology results showed non-small cell carcinoma and oncology was consulted.

Jonathan Storm showed improvement over the next 4 days, was afebrile, and was weaned to room air by 1/12/2021. He was observed for 2 additional days and discharged home on oral linezolid to complete 4 weeks of treatment per Pulmonary recommendations.

Laboratories

Imaging

  • 1/3/2021 CXR RML pneumonia
  • 1/7/2021 Chest CT right hilar mass with almost complete obstruction of the right mainstem bronchus

Procedures

Consults

  • Pulmonary: Dr. Tony Stark, office contact 555-555-1111
    • Recommendations
      • Continue linezolid for a total of 4 weeks.
      • Follow-up in Pulmonary clinic
  • Oncology: Dr. Peter Parker, office contact 555-555-1112
    • Recommendations
      • Agree with antibiotics per Pulmonary team
      • PCP to follow up pathology report and notify the Oncology service
      • Follow-up in Oncology clinic for staging and to discuss treatment options

Discharge condition: discharged to home in good condition

Patient instructions

  • Activity as tolerated: Avoid strenuous activities if shortness of breath is present.
  • Regular diet
  • See your regular doctor or notify the pulmonary clinic if you develop a fever or your cough worsens.
  • Return to the ER if you are coughing up blood, your shortness of breath worsens, or you are unable to take your medicines by mouth.
Follow-up appointments
1/18/21 at 09:00 am PCP Dr. Carol Danvers
1/20/21 at 10:00 am Pulmonary (lung) clinic

Dr. Tony Stark, office contact 555-555-1111

1/21/21 at 09:30 am Oncology (cancer) clinic Dr. Peter Parker, office contact 555-555-1112

Medications

  • No home medications prior to admission
  • Continue linezolid 600 mg by mouth every 12 hours for 21 days (last dose 2/4/2021).
  • Handout provided to the patient on foods and medications to avoid while taking linezolid
  • PCV23 vaccine administered in hospital on 1/13/21

PCP Instructions

  • PCP follow-up 1/18/21
  • Weekly CBC while taking linezolid to monitor for thrombocytopenia and neutropenia: Fax the results to the pulmonary service and call if the results are abnormal.
  • Follow-up pending pathology results from lung biopsy done on 1/8/2021 and notify Oncology of results.
  • Coordinate care with the Pulmonary and Oncology services.

Signature

Wanda Maximoff, MD 1/14/2021 1645

PGY-1 Resident

Natasha Romanova, MD

Attending physician

Pager 555-555-1113

General

  • Event notes should be placed in the EMR for any event that requires a medical decision.
  • The more significant the issue, the more quickly a note should be written in order to document appropriate care.
  • Examples include:
    • A nurse calls for a bedside evaluation of a patient.
    • Changes in the medical plan: e.g., adjusting insulin doses based on glucose values; switching antibiotics based on sensitivity results
    • Placing EMR orders based on a consultant's recommendations
    • Documenting you saw a laboratory result and your decision/plan regarding the result

Example of an event note

Event Note
Situation
  • 2230: Called to bedside by patient's nurse for increased respiratory distress and worsening O2 saturations
Objective findings
  • The patient was noted to be in respiratory distress with intercostal retractions and tachypnea.
  • Wheezing present bilaterally with diminished breath sounds at bilateral bases
  • Pulse ox 88% on 0.5 L of O2 via NC
Action(s) taken
Response to intervention
  • 2300: The patient showed significant improvement in respiratory status.
Plan

Write a quick event note each time you are called to a patient's bedside. A brief update can be placed at the bottom of the note for each subsequent return to the patient's bedside. Consider using SOAR-Plan to remember the elements of an event note: Situation, Objective findings, Actions taken, Response to intervention, Plan.

Other examples

Event notes can be separate notes or can be added as addendums to recent notes. Do not alter previous notes, but add new updates at the bottom of preceding notes in chronological order. State if it is a late entry and document the time the action was taken.

  • Brief event note with update
    • 19:00 - Called by the bedside nurse because the patient has not defecated in 2 days and feels the urge to stool. Per nursing, patient is in no distress and no pain. Chart review shows the patient has been on opiate pain medications for a broken tibia, normal vitals. Ordered glycerine suppository and asked the nurse to update me in 2 hours, sooner if needed. Resident’s name, time, and date
    • 21:05 Update - Per bedside nurse, patient had a moderate BM following the glycerine suppository and feels much better. Plan: scheduled daily docusate sodium and ordered polyethylene glycol 3350 PRN while on pain medications.
  • Action update note

Always include your name, credentials/role, time and date, and contact information at the bottom of all notes.

Signouts (also called handoffs or handovers) are a formal way to transfer care of your patients to another provider. Signouts provide information that enables the accepting provider to provide the best care possible.

General

  • Significance
    • The number of medical handoffs has increased with duty hour limitations.
    • More handoffs increase the potential for communication errors.
    • Effective signouts
      • Reduce medical errors and adverse patient outcomes
      • Enhance team communication
      • Provide the ability to be proactive rather than reactive
  • Prepare the environment
    • Find a quiet space relatively free of distractions.
    • Let the nursing staff know when team signout times occur in order to minimize disruptions.
    • Assign someone to answer pages/phone calls and take notes on nonurgent matters when someone is presenting.
  • Do:
    • Use standardized handoffs for both verbal and written signouts to avoid omitting crucial information: See “IPASS” and “ISBAR/SBAR.”
    • Leave time for questions and synthesis after each patient to ensure instructions are clear.
    • Provide contact information for a family member on the written signout sheet if it is not easily accessible in the EMR.
  • Do not:
    • Repeat the entire HPI.
    • Leave tasks for the overnight resident. Do your best to finish as much as possible during the day, and sign out only urgent tasks.
    • Criticize care decisions made by your colleagues; e.g., avoid comments like “I have no idea why John/Jane sent that test yesterday; it's totally unnecessary.”

IPASS

IPASS is a validated handoff communication tool that has been shown to decrease medical errors associated with shift changes and transfers of care between teams. [6]

  • I - Illness severity
  • P - Patient summary
  • A - Action list
  • S - Situation awareness and contingency planning
  • S - Synthesis by the receiver

IPASS example

The following IPASS example is one sample row from a signout list, which would include all patients on the service.

IPASS signout example
Patient information Illness severity/code status/contact information Patient summary Action list Situation awareness &
contingency plan
Synthesis by the receiver
  • John Doe
  • DOB 1/1/1965
  • Room 516
  • Improving, stable.
  • Full code.
  • Contact: wife Julie at 555-555-5555
  • 20:00- Check JP drain output; if < 25 mL/past 24 hours, call General surgery to remove drains.
  • Use this space to clarify questions during signout.

There will always be instances in which it is necessary to seek the medical opinions of other physicians, whether from consulting services or more senior physicians (residents or attendings). Effective communication of medical information allows for more effective and more timely patient care.

Requesting consults

  • Early: Call consulting services as early as possible in the day.
  • Standard format: Consider using the ISBAR tool to prepare how to address a busy consultant.
    • Identification: i.e., yourself and the patient
    • Situation: Lead with the reason why this specific consultant's opinion is required.
    • Background
      • Limit yourself to information that directly relates to the request for consultation.
      • Provide more background details if requested.
    • Assessment: State your working impression, mention any uncertainty that warrants the consultant's attention.
    • Recommendation: Let the consulting service know how quickly the consult is needed.
    • See also “Tips and links” for the CONSULT mnemonic.
  • Synthesize
    • Ask if the consulting service has any questions.
    • Get a time frame on when to expect the consult and exchange contact information.
  • Order: Place an order for the consult in the EMR.

If a specialist follows your patient as an outpatient for a diagnosis that does not actively need to be addressed, consider calling the patient's primary specialist before ordering an inpatient consult. This can sometimes prevent an unnecessary consultation from a different specialist and preserve the continuity of care.

ISBAR/SBAR examples

ISBAR examples
Mnemonic Components Calling the senior resident Calling a consultant
I
  • “This is Dr. T'Challa, the intern on the hospitalist team taking care of Mr. Jones in room 516 on the Surgical floor.”
  • “This is Dr. Harkness, the intern on the hospitalist team taking care of Ms. Jones in room 517 on the medical floor.”
S
  • “I am calling because Mr. Jones is confused and disoriented.”
  • “I am calling for a Pulmonology consult because Ms. Jones is admitted for status asthmaticus and needs a medication adjustment.”
B
  • “He is a 70-year-old male who had surgery for a broken hip 3 days ago. He appeared fine during my shift yesterday, but he is very confused now.
  • “His last dose of pain medication was 3 hours ago and has not been increased in the past 24 hours.”
  • “The nurse reports his indwelling urinary catheter has had decreased output this shift and looks cloudy.”
  • “His blood pressure is lower than on previous shifts and he is tachycardic at ∼105 bpm.”
  • “He finished his 3 post-op doses of cefazolin 24 hours ago. On exam, his capillary refill is delayed and he is not oriented.”
  • “This is her third admission in the past 9 months, despite being adherent to her salbutamol and trained in proper inhaler technique.”
A
  • “I am concerned Mr. Jones may have catheter-related urosepsis.”
  • “She is currently stable, but we think that she might benefit from regular inhaled corticosteroids as she has a high risk of relapse. We are unsure if she is allergic to any environmental triggers.”
R
  • “I have ordered a 1 L NS bolus, urinalysis, blood and urine cultures, and started IV meropenem.”
  • “Will you please come evaluate this patient?”
  • “Should I replace his urinary catheter, and notify the ICU team?”
  • “She will likely be discharged in the next 24 to 48 hours, and we would appreciate your evaluation prior to her departure, thanks!”

Organization

  • Start your shift by receiving signout; ask questions if signout is unclear.
  • Prioritize sick patients.
    • Introduce yourself to sick patients and their nurses at the beginning of your shift.
    • Touch base with the senior or attending to discuss these patients.
    • A patient with a serious acute event always takes priority to other tasks.
  • Make sure necessary orders for patients are entered prior to starting lengthy documentation.
  • Triage your to-do list; see “Organization tips and work hacks.”
  • Have medical references easily accessible; see the “On-call survival guide” in “Tips & links.”

Communication

  • If you are on a medical floor, let the nurses know and ask if they have any questions.
  • Notify your upper level/senior resident and/or attending of any significant events that occur.
  • If you have two urgent/emergent issues at the same time, call your upper-level resident to help you.
  • Review communication tips for family members of patients you are cross-covering (see “Communication during residency”).

Documentation

  • Write things down.
    • Document event notes and patient updates.
    • Note tasks you have done and still need to do.
  • Write quick admission notes with the full H&P to follow; finish admission notes during slower times.

Wrap-up

  • Dedicate time before morning signout to wrap up loose ends and update the team list before signout.
  • Make sure you can safely drive home. Nap in your car before driving, if necessary. See “Fatigue management” in “Life outside the hospital.”
  1. Lichstein PR, Atkinson HH. Patient-Centered Bedside Rounds and the Clinical Examination.. Med Clin North Am. 2018; 102 (3): p.509-519. doi: 10.1016/j.mcna.2017.12.012 . | Open in Read by QxMD
  2. Fletcher KA, Bedwell WL, Frick SE, Telford BN. Enhancing training with well-designed checklists. International Journal of Training and Development. 2018; 22 (4): p.289-300. doi: 10.1111/ijtd.12139 . | Open in Read by QxMD
  3. Storesund A, Haugen AS, Flaatten H, et al. Clinical Efficacy of Combined Surgical Patient Safety System and the World Health Organization’s Checklists in Surgery. JAMA Surg. 2020; 155 (7): p.562. doi: 10.1001/jamasurg.2020.0989 . | Open in Read by QxMD
  4. Kind AJH, Smith MA, Henriksen K, Battles JB, Keyes MA, Grady ML. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care. Advances in Patient Safety: New Directions and Alternative Approaches. 2008; 2 .
  5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Gen Intern Med. 2009; 24 (8): p.971-976. doi: 10.1007/s11606-009-0969-x . | Open in Read by QxMD
  6. Starmer AJ, Sectish TC, Simon DW, et al. Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA. 2013; 310 (21): p.2262. doi: 10.1001/jama.2013.281961 . | Open in Read by QxMD