D
Decision making - Explain diagnostic and therapeutic plan
Documenting
Guide for Documentation in the Medical Record
O
Organization
C
Communicate clearly
Chronology of events
Compensation
U
Unapproved abbreviations - Do not use
M
Medical legal document - thorough, accurate, and factual
E
Error correction - Strike out. Do not alter.
N
Need date and time
T
Timely - Any change in patient status or management plan
I
If you don't document it, it didn't happen
Identification - Make sure you document in the right chart
N
Name - Print and/or stamp under your signature
Neat - Must be legible
G
Go over your dictation before signing
Aditi Singh, MD and Sandhya Wahi-Gururaj, MD, MPH
Signout?
Guide for Oral Sign-Out Skills
S
Sick or DNR? - highlight sick or unstable patients
identify DNR/DNI patients
I
Identifying data - name, age, gender, diagnosis
G
General hospital course
N
New events of day
O
Overall health status/clinical condition
U
Upcoming possibilities with plan, rationale
T
Tasks to complete overnight with plan, rationale
?
Any questions?
Horwitz, L, Moin, T, and Green, M. Development and Implementation of an Oral Sign-Out Skills Curriculum. JGIM 2007 October; 22(10): 1470-1474.
Soaps
Guide to Teaching Oral Case Presentations
S
Story - Identifies and describes complaints
O
Organization - Facts are where the listener expects
A
Argument - "Makes the case" for the assessment and plan
P
Pertinence - Only includes information relevant to the assessment and plan
S
Speech - Fluent, well spoken and not read
DeCherrie, L, Fagan, M, Green, E, Greenwald, J, Hershman, W, Sharpe, B, Torres-Finnerty, N, Wahi-Gururaj, S and Wiese, J. Making SOAPS safer. POGOe - Portal of Geriatric Online Education; 2006 Available from: http://www.pogoe.org/productid/18900
Safety
Resident Guide for Attending Input
S
Seeking attending input early often prevents delays in care
A
Active clinical decisions (e.g. surgery) should be made after contacting your attending
F
Feeling uncertain about clinical decisions is normal - you should contact your attending
E
End of life care decisions change the course of care, and the attending should be aware of the discussion
T
Transitions of care - Contact your attending if someone is being discharged or transferred
Y
sYstem difficulties and hierarchy may hinder patient care - attendings can help expedite care through direct involvement
Farnan JM, Johnson JK, Meltzer DO, Harris I, Humphrey HJ, Schwartz A, Arora VM. Strategies for effective on-call supervision for internal medicine residents: The SUPERB/SAFETY model. Journal of Graduate Medical Education. 2010;2(1):46-52.
Superb
Guide for Attending Supervision
S
Set expectations for notification – Be notified when a patient is being discharged, transferred, going to surgery, dies, or leaves AMA
U
Uncertainty – Ask the resident to contact you when feeling uncertain about specific decisions
P
Planned communication – Set a time to talk to your resident on call nights and before leaving the hospital each day
E
Easy availability – Provide resident with your contact information
R
Reassure fears – Reassure the resident that calling is not a sign of weakness and that you would not be upset by the call
B
Balance supervision and autonomy – Tailor for level of resident experience
Farnan JM, Johnson JK, Meltzer DO, Harris I, Humphrey HJ, Schwartz A, Arora VM. Strategies for effective on-call supervision for internal medicine residents: The SUPERB/SAFETY model. Journal of Graduate Medical Education. 2010;2(1):46-52.