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RESPONSIBILITIES OF THE HO-1
The HO-1 is the
primary care physician and is therefore responsible for the day-to-day care of
the patients. All orders should be written by the HO-1 responsible for the
patient or by the HO-1 covering that service. All HO-1s should be prepared for
work rounds at 8:30 a.m. (i.e. pre-round on patients). The HO-1 should check on
critically ill patients, take care of discharges, review lab work, etc. prior
to rounds in order to allow work rounds to proceed smoothly and efficiently. All
scheduled discharges for that day should have paperwork done the day before
to facilitate this process.
ROUNDS
Work rounds
should begin with students and HO-2/3 at 8:30 a.m. on weekdays and at a
time on weekends to be arranged by mutual agreement (ultimately at the
discretion of the HO-2/3).
HO-1s are
required to attend Morning Report when on elective/outpatient months. They are
encouraged to attend whenever their daily schedule permits.
PATIENT CENSUS
The optimal
number of ward patients per HO-1 is 8-10. Patient loads should be regulated
primarily by the HO-2/3. These figures vary with the type of patients admitted
and the severity of the illness. The principal concept is that the workload
should be closely monitored by the HO-2/3, Assistant Chiefs of Medicine,
attending and Housestaff Executive Committee. See
attached call system revision that monitors rotation census and admission caps.
For any problems, the ACMs and Program Director should be notified ASAP.
NOTES
The HO-1’s
written admission note should be placed on the chart upon the patient’s
admission and the History and Physical must be dictated/entered
electronically within 24 hours. Progress notes must be written daily for
all patients. Notes written by medical students should be reviewed, corrected and
SIGNED by the upper level resident, who also needs to write a small
addendum to those notes (see last memorandum attached). All house officers will
receive notification of delinquent dictations and/or electronic notes from
medical records. No vacations or study
leave will be approved if a resident has delinquent dictations or electronic
notes outstanding.
ADMISSIONS
During the day,
HO-1s should immediately notify their upper level resident of new admissions.
At night, HO-1s must call their backup ROC to see any admissions that were not
previously evaluated by the HO-2/3 in the ED (i.e. “direct admissions”).
SIGN-OUT
All HO-1s are
required to give a written list of his/her patients to the HO-1 on call with
brief but specific data including diagnosis and anticipated problems when
signing out for the evening. Further, the HO-1 on call, when called to evaluate
a patient for a problem, is encouraged to write a brief note describing the
problem, their assessment, and the treatment employed.
SIGN-IN
The morning
after call, the INOC should provide the daytime interns and resident with an
update of the status of all patients covered overnight. This will include a report of studies checked
out to the INOC the night before, as well as a patient list that includes new
patient demographic data, location, problems, and plans.
OFF SERVICE
Well organized off-service notes are expected to be
written by HO-1s on the last day prior to changing services. These should
detail the patient’s hospital course, list active problems and their therapies,
and include a list of current medications and any pending labs. The purpose of
off-service notes is to allow excellent continuity of care and help decrease
the stress of picking up a new service of patients.
CLINIC
During most
months, each HO-1 will work one half-day per week in their continuity care
clinic. Interns on wards are expected to hand off their inpatients to their
upper level resident before going to clinic. Upon completion of clinic, the
intern is to call their upper level resident to get updates on their
patients. Each intern will have clinic
on the same day each week. Attendance in
clinic is required unless the HO-1 is on vacation. All HO-Is must submit clinic
date changes to Christine Brandon via New Innovations (contact Chris for
help @ 6-9660 or cbrandon@wfubmc.edu).
Requests must be submitted 2 months prior to the desired
date.
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RESPONSIBILITIES OF THE HO-2/3
The HO-2/3 is the leader of the medical care team
on each service and is responsible for keeping the “pulse” of the service. The
HO-2/3 should lead work rounds and report to the attending physician daily. The
HO-2/3 on the ward services should be in the hospital from 7:00 a.m. to at
least 6:00 p.m. on weekdays. During the weekend the HO-2/3 is responsible for
making rounds with the attending on either Saturday or Sunday.
NOTES
Daily progress notes by the HO-2/3 are required in
the ACE unit and may be needed in high-volume/high-acuity settings (e.g. the
MICU).
All HO-2/3s not in the CCU or ICU are required
to attend Morning Report. Punctuality is
expected.
CALL
ED CALL
An HO-2 (ED) is assigned to the Emergency
Department every night and 24-hours on weekends. He/she is responsible for
directing balanced admissions among the services and is responsible for briefly
presenting at morning report’s “fresh case” that are interesting or challenging
ED consults.
During evening shift (3 pm-midnight),
an HO-3 ED resident from the ROC group will be present in the ED and will
alternate patient consults with the on call HO-2. After midnight, backup is and
should be called when the resident is 2-3 consults behind. For help after midnight, the backup hierarchy
is as follows: SSOC, GMOC, and HO-3. The ICU and CCU residents are responsible
for admissions from the ED to their services.
As Emergency Department consultant, the HO-2/3
should freely request backup consultations from the HO-3, the fellow on call
for a particular subspecialty, or the attending physician.
Any patients
discharged from the ED by the HO-2 must be discussed with the HO-3 on call or
with an Internal Medicine Attending physician.
When admitting patients to the IMC, the covering
GMOC/SSOC should be notified.
Any admissions to the Day Hospital must be
discussed with the WFIP Attending physician prior to the admission.
When admitting patients to the IMC, the covering
GMOC/SSOC and the Attending physician should be notified.
Any admissions to the Day Hospital must be
discussed with the WFIP Attending physician prior to the admission.
Subspecialty
Service On-Call (SSOC)
SSOC resident is responsible for
1.
Primary
coverage of BMT, including all new admissions.
2.
Backup
for interns on all subspecialty services.
3.
Evaluation
of all subspecialty direct admissions and brief upper level admission notes
(emphasis on assessment and plan).
4.
Written
admission H&P for direct admissions to the Cards B service after 6pm.
5.
HO-3
serves as backup for SSOC resident
Gen Med On-Call (GMOC)
The GMOC is responsible for
1.
Primary
coverage of ACE unit, including all new admissions.
2.
Backup
for interns covering Gen Med services.
3.
Evaluate
all Gen Med direct admissions and write brief upper level admission notes
(emphasis on
assessment and plan).
4.
Maintain
intern autonomy by allowing intern to evaluate patient first.
5.
Do
all primary H&P’s and admission orders on any admission after Gen
Med intern(s) reach cap.
6.
HO-3
serves as backup for GMOC resident.
DISCHARGE SUMMARY
HO-2/3s should dictate all discharge summaries within
24 hours of discharge. Different sections of the Department of Medicine may
employ varying discharge note formats. HO-2/3s should consult the Director of
the section and the attending physicians for their formats. If not directed
otherwise, dictations should include a brief one paragraph summary of the
history and physical, pertinent admission laboratory data, and a concise and
cogent account of the hospital course.
(A problem-oriented approach may work best here.) A
list of diagnoses, discharge medications/logician reconciliation, and
disposition should also be included.
DAYS OFF
On ward rotation, the HO-2/3 must ensure that each
intern has one day (24 hours) off per week (i.e. one weekend day). The HO-2/3
must also have (1) day off each week averaged over the rotation. These days
should be agreed on with the attending, at the beginning of the month. When the
HO-2/3 is off, the attending is responsible for rounding with the HO-1s.
TRANSFERS
Whenever a patient on a ward service requires
transfer to either the ICU or CCU, the HO-2/3 on the wards is required
to provide the intensive care team with a concise and complete transfer note
detailing the patient’s problems and any special therapeutic considerations.
This practice allows for the best continuity of care when the new team assumes
responsibility. In addition, any patient transfers from a non-medical service
to a medicine ward team will have an HO-2/3 accept note summarizing
pertinent history, physical exam, and impressions/plans.
CLINIC
Each HO-2/3 will be assigned an afternoon in clinic
on a fixed day. Additionally, during selective/elective months a second
half-day per week will be scheduled in the morning. Pagers must be on until 6:00 p.m. Monday –
Friday for clinic, except on ROC rotations.
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RESPONSIBILITIES OF THE HO-3
When functioning as a ward upper level resident,
the responsibilities for the HO-3 are the same as listed in the HO-2 section.
CONSULTS
The HO-3 performs all inpatient consults to the
Department of Internal Medicine after 6:00 p.m. All consults must be
provided with adequate follow up.
Each preoperative consult should be discussed
with the General Medicine attending on call for UIMA or the on call WIFP
attending. These consults will all be staffed within 24 hrs. To ensure
continuity through the weekend, all new consults should be checked out before 8
a.m. the following morning to the AIM resident. Non-preoperative consults do
not require a call to UIMA attendings, unless the
HO-3 feels he needs attending input.
TRANSFERS
Often, when consulting on off-service patients at
night, or on weekends, the issue of transfer to a medical service arises. The
HO-3 will make this decision based on the patient’s problem and condition while
always keeping the patient’s best interest in mind. Usually the HO-3 is able to
assist the surgical service with attentive follow-up in order to help them
manage the problem more effectively. If transfer is still an issue the
following morning (or on Monday) then it becomes the responsibility of the
HO-2/3 on AIM and their medical attending. Additionally, during weekdays any
requests by non-medical services to transfer a patient to Medicine should be
directed to the General Medicine consult team.
ED CONSULTATION AND BACKUP
The HO-3 on the daytime ED/UIMA rotation is the
admitting resident during the day. When the ED/UIMA HO-3 resident is in his/her
continuity clinic, one of the residents on the Medicine Consult service (AIM)
will cover the ED (schedule available).
If the ED resident is more than two (2) consults behind, the Medicine
Consult residents may also be called to provide backup.
From 3 pm-midnight, a second HO-3 from the ROC
service (HO-3 ED) will be present in the ED and will work with the daytime
ED/UIMA HO-3 until 6 pm and the ROC HO-2 ED from 6 pm-midnight. After midnight, the ROC HO-2 ED alone is
assigned to the ED. As outlined
previously, the ROC HO-3 is the primary backup for the ROC HO-2 ED after
midnight and will check in with the HO-2 ED periodically to offer assistance if
needed.
The HO-3 daytime ED resident covers overnight OPD
clinic calls. HO-3 is also expected to cover clinic related calls during any
weekday holiday when the OPD clinic is closed.
The ROC HO-3 on call in the evening is the resident
in charge of all medical services; thus, all unresolved problems should
ultimately be referred to him/her. The HO-3 should be consulted on difficult
management problems before a fellow or attending is called.
INTERNAL MEDICINE RESIDENT GRAND ROUNDS (RGR)
Each HO-3 is responsible for preparing one RGR. The
HO-3 is encouraged to review a topic in the context of an actual patient
management problem. Less than twenty (20) references should be evaluated. The
presentation should last 45 minutes. HO-3s are encouraged to seek a faculty
advisor to assist in preparation, review the finished product, and provide
feedback. The presentation should be accompanied by a brief handout emphasizing
important points (no more than two pages).
Refer to separate educational packet regarding
preparation for this conference.
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OBLIGATIONS OF THE ASSISTANT CHIEFS
OF MEDICINE
The Assistant Chiefs of Medicine (ACMs) report
directly to the Department Program Director/Chairman and as such function as
their executive officers for the house staff training program. The ACMs thus
carry significant authority among the house officers and faculty, and work
closely with other faculty as members of the House Staff Executive Committee.
The ACMs are involved in the design and execution of many features of the
educational program.
The ACMs are the principal liaison between the
house staff and the Department of Internal Medicine. They will monitor house
staff functions in both in-patient and ambulatory activities, and maintain
balance on services within the Department of Medicine. The ACMs are appointed
to the faculty of Wake Forest as instructors and serve as ward
attendings on General Medical services. They have many
other administrative and teaching responsibilities as well but are primarily house
staff advocates. They are, therefore, your first line of support if any
problems emerge.
One of the ACMs is always available 24 hours per
day for any personal or patient care urgencies. The ACM-on-call can be accessed
by calling the PAL Operator @ 6-7654.
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The ultimate authority for the
Graduate Program of the Department of Medicine is the Chairman.
Dr. Peter Lichstein is the Program Director and has
acting responsibility for all house staff affairs. Dr. David Miller supervises
the Primary Care Track and thus represents his residents in their particular
concerns.