Department of Medical Education Extern Manual Updated 2014

Department of Medical Education Extern Manual Updated 2014 General Information Housing Garden City Hospital offers student housing to osteopathic medical students on a firstcome, first-served basis, primarily for students who are visiting from out of state. Apartments are furnished and are located within walking distance or a short drive from the Hospital. Linens, towels and housekeeping services (every other week) are provided by the Hospital. There is a (Non Refundable) nominal fee of $50 for a 4-week rotation or $25 for a 2-week rotation. Meals Food is available while on duty at the hospital cafeteria, located on the lower level and may be charged using your ID badge. Meals are provided to students free of charge, but please note the following: You may only charge food for yourself on your account You may not charge food in the Garden Café located in the Main Lobby Food is available for purchase (cash or credit card) in The Vending Room located on the first floor of the hospital past the courtyard. Parking Externs are expected to park in the Harrison lot and take the shuttle to the hospital. The exception would be that students assigned to night shifts (e.g. in the Emergency Department or Labor and Delivery) may park in the house staff parking area on the main campus. You may not park in any visitor parking or in the gated lots reserved for attending physicians. Parking tags must be displayed in your vehicle. ID Badge You will be provided with a photo ID badge which is to be worn at all times while on duty at the hospital. Your badge permits you to access areas of the hospital including the House Staff Lounge, ED, ICU, etc. and allows you to charge food in the cafeteria. Lost badges can be replaced in Human Resources during regular business hours. There is a fee for replacement of lost badges. Badges must be returned at the conclusion of your rotations at GCH. Dress code, lab coats and scrubs Externs are expected to promote the Hospital s image by maintaining a professional appearance. Clothing should be clean, neat and conforming to professional standards for men and women. Men are expected to wear slacks, shirt and tie. Women are expected to wear slacks, skirts or dresses; blouses that are low-cut or have a bare midriff are not permitted. Jeans, shorts and sandals are not permitted. Lab coats are to be worn in patient care areas and are to be clean. 1

Scrubs are available in the surgery department. Scrubs are the property of Garden City Hospital and are to be returned after use. Scrubs should not be worn to or from work; rather, one should change into scrubs at the hospital and remove them prior to leaving. Scrubs are only to be used on surgery, OBGYN and Emergency Medicine rotations. Lectures You are expected to attend lectures while on rotation at GCH. The lecture schedule will be posted and sign-in sheets are available. Lectures are scheduled most days at 7:15 am and 12:00 noon on most weekdays. The majority are held in Classroom A/B or in the Medical Auditorium. You may bring food from the cafeteria to lectures; however, please dispose of items properly. Your service should release you so that you may attend lectures; if this does not happen, please contact Medical Education. Evaluations Your school provides an evaluation form that is to be completed by a supervising physician on each rotation and then returned to Medical Education. It is highly recommended that you ask for feedback along the way during your rotation, and that you ask the physician completing the evaluation if you can review it together. This provides you with more direct feedback and also helps to ensure that the supervising physician completes the form in a timely fashion. Time Off During Rotation ( to be determined by the following factors) A. Individual s College Policy B. GCH Preceptors Ability to Accommodate Request Representing yourself While on rotation at GCH, you may identify yourself to patients and visitors as Student Doctor Jones or Adam Jones, Medical Student. Do not represent yourself as Dr. Jones. When meeting a patient, a suggested acronym is AID: Acknowledge: greet the patient by name Good morning Mrs. Smith. Introduce: introduce yourself and your role I m Student Doctor Jones and I m a medical student working with Dr. Roberts. Describe: indicate why you are there/how long it will take I need to review your history and do a physical examination. This should take about 30 minutes. I know you ve told other people about your medical history. But we want to take excellent care of you here so it s important that we make sure we have complete and accurate information about you. Surgery On-Call Schedule Externs and interns on surgery rotations will be assigned to a surgery on-call schedule. Each day one extern or intern will be the go-to person if another attending is in need for assistance in the OR. On your assigned day, you should complete your regular duties on your surgery service but be available should you be needed elsewhere. You are expected to check out with the surgery desk if you are leaving the building and at the end of the day. 2

Patient evaluation and documentation Hospital charts GCH currently utilizes a paper-based medical records system for physician charting, in tandem with an Electronic Health Record (EHR) for other clinical documentation and order entry. A few caveats for students regarding charts: You are encouraged to take time to review charts of assigned patients thoroughly in order to learn. But in the interest of patient care, but be respectful of attendings and other providers who need access to the chart and charting areas. If another provider needs a chart, please be courteous. Do not remove a chart from the unit secretary s chart rack without permission. Do not remove charts from the nursing unit. All information in the paper and electronic medical record is confidential and protected under HIPAA. Externs are expected to only access the records of patients on service or otherwise assigned. Student access to EHR and orders Garden City Hospital utilizes an Electronic Health Record (EHR) for Computerized Physician Order Entry (CPOE). Externs will be provided access to the EHR to view clinical documentation, results, etc. Externs assigned to Garden City Hospital as a base institution will have limited access to enter orders in CPOE for co-signature by a supervising physician, designated when the order is placed. Orders are not active until co-signed. Externs here for shorter durations do not have access to enter orders. Progress notes Externs are encouraged to write progress notes on assigned patients using the SOAP format. Progress notes are entered in the paper chart, and must be reviewed/co-signed by a supervising physician. As a review, SOAP stands for Subjective: symptoms Objective: vitals, general assessment, physical exam, results of labs and studies Assessment: principle and secondary diagnoses, progress Plan: for the day and for the stay medications, further diagnostics, consultations, discharge planning, etc. Correcting errors If an error in documentation is made, it should be corrected as follows: Draw a single line through the error in ink, making sure that the entry is still legible. Entries should never be erased, made illegible, or covered up with liquid correction fluid. The correction should be dated, timed and signed or initialed by the individual making the correction. A note should be placed near the correction stating why the entry was changed, e.g. error, wrong patient, wrong chart. 3

Prohibited abbreviations Garden City Hospital has a list of accepted abbreviations (see Hospital Policies section of this Manual). Additionally, certain abbreviations are prohibited when documenting in the chart: DO NOT USE Abbreviation Intended Meaning or Explanation Why This is a Problem Do this Instead U unit May look like a zero Write out unit IU QD or qd QOD or qod X.0 (e.g. 5.0 mg) _.X (e.g..5 mg) MS MSO4 MgSO4 international unit daily every other day trailing zeros following decimal points lack of a leading zero before decimal points morphine sulfate or magnesium sulfate morphine sulfate or magnesium sulfate magnesium sulfate May look like the number 10 May be interpreted as wrong interval 5.0 may be read as 50.5 may be read as 5 May be interpreted as wrong drug Write out int l unit Write out daily or qday Write out every other day Do not use trailing zeroes Be sure to use a leading zero Write out name of drug History and Physical examinations You will be assigned to complete H&P s during your rotations here. Attempts are made to assign H&P s based on the service or specialty you are on but you may be assigned an off-service H&P. Guidelines for completion of the H&P form are attached. You will be assigned on a rotating basis to an H&P shift, which means that you will be available to complete H&P s between the hours of 5:00 pm and 8:00 pm. A schedule will be provided and has the appropriate house staff contact person listed. H&P s must be reviewed & signed off by an intern, resident or attending. A form called Evaluation of Student Assigned H&P Shift will be the student s responsibility to have completed, acquired appropriate signatures, along with returning the document to Med Ed Office after each shift. Please note even if the assigned student is dismissed earlier that day from rotation, the student is still expected to come back to the Garden City Hospital to perform and complete scheduled shift assignment. * Filling the MSU Core IM 650 night call requirement is done by logging into the ENCORE Patient Encounter Logging System with the H&P s between 5:00 pm and 8:00 pm assignments. Another valuable enrichment opportunity is shadowing a house officer and arrangements are made through Med Ed office. 4

H&P Guidelines An H&P is to be completed as soon as possible but within 24 hours of admission. The six page H&P form serves as both H&P and admission note. An admission note will be written if the H&P is not completed at the time of admission. The H&P may be completed up to seven days prior to admission, as for patients undergoing surgery. An interim H&P may be performed on patients who had a complete H&P performed on a prior admission to this hospital within thirty (30) days. The interim H&P must reference the prior H&P, and must include an interim history and a new complete physical examination. It is not acceptable to merely provide a photocopy of a prior H&P or a note to see prior H&P without additional documentation. The attending physician must review and sign the H&P, and may add additional information or make corrections. Required elements of the H&P: H&P s must include the patient s point of origin, e.g. where the patient was prior to admission or presentation to the Emergency Department. Examples are: Home ECF (extended care facility) Rehab unit Direct admit from physician office Transfer from other institution Etc. H&P s must include a complete physical examination. This includes examination of the genitalia and rectum. If these or any other portion of the physical examination is not performed, the reason must be clearly documented on the H&P form. It is not sufficient to say refused or deferred (see more guidelines below). The physical examination also includes an osteopathic structural examination (OSE), to be documented on the H&P form. Instruction on completing the OSE will be provided and assessed as part of the orientation program for incoming house staff. H&P s must include documentation of present on admission (POA) conditions, which may be chronic or acute. These conditions must be detailed in the Impressions section of the H&P. Skin findings must be noted in the appropriate section on page 5 of the H&P form. Chronic medical diagnoses (e.g. diabetes) Newly diagnosed abnormalities, (e.g. hyperglycemia on ER labs). Such abnormalities must be listed by their medical term, not by symbols, e.g. hyponatremia not Na + Evidence of infections (especially abnormal urinalysis suggesting UTI) Presence and accurate description (stage, size) of any skin breakdown or decubiti Documentation of impressions and plan should correlate with reason for admission, e.g. severity of illness and intensity of service (see Care Status above). 5

Guidelines for completion of the Review of Systems portion of the H&P form are as follows: Negative findings (absence of the symptom or condition) are to be designated by CROSSING OUT the prompt. Positive findings (presence of symptom or condition) are to be designated by CIRCLING the prompt. Positive findings are to then be described in the space provided. As not all prompts are necessarily relevant for all cases, prompts that are neither circled nor crossed out will be interpreted as not asked. Additional symptoms or conditions, e.g. those for which no prompt is given but are relevant to the patient, may be described in the space provide. These may be either positive findings or negative findings and should be so described. Guidelines for completion of the Physical Examination portion of the H&P form are as follows: Positive findings (presence of finding) are to be designated by CIRCLING the prompt Positive findings are to then be described in the space provided. Since each area is being examined for any deviation from normal, prompts that are neither circled nor crossed out will be interpreted as negative or absent. Additional findings, e.g. those for which no prompt is given but are relevant to the patient, may be described in the space provide. These may be either positive findings or negative findings and should be so described. Examinations that are not performed or are deferred need to be documented as to the reason why. Pelvic and rectal examinations are considered part of a complete H&P, and are a critical component of the evaluation of certain patients (e.g. those with abdominal pain). If, from a clinical standpoint, these examinations may be reasonably deferred, the notation in the chart should provide detail, such as Pelvic examination deferred. Done by OBGYN last month, normal per patient or Rectal exam done by GS resident. See consult. 6

Hospital policies and procedures Disaster and emergency codes and drills Means Student/House Staff Role Cardiopulmonary arrest House officers and Internal CODE BLUE Medicine Residents report may be excused CODE TRIAGE Internal or external disaster See duties below CODE PINK Infant/child abduction < 1 year old Be alert for people with packages leaving the building CODE PURPLE Child abduction > 1 year old N/A CODE ALPHA Administrative team alert Stand by for possible code triage Severe weather Stand by for instructions CODE BLACK may need to assist in moving patients to safety Fire Stand by for instructions CODE RED may need to assist in moving patients to safety CODE CLEAR All clear, resume normal operations N/A CODE ORANGE Activate Chemical/Biological/Radiation Plan N/A CODE YELLOW Activate Bomb Threat Plan N/A CODE SILVER Respond to person that may have a weapon N/A CODE STRONG Activate Code Strong Team for combative person N/A Instructions for code blue Externs on Internal Medicine rotations may respond to code blue calls to observe. You may have the opportunity to do chest compressions and/or assist with procedures. Please keep in mind that the goal of an ACLS response is to resuscitate the patient and as such you may not have the opportunity to perform these tasks. It is also asked that the number of individuals in the room be limited. If you are not needed to assist, please excuse yourself from the room. Instructions for code triage (internal or external disaster) Code Triage is an alert for the administrative team to assemble in response to an internal or external disaster or other urgent situation. Students and house staff do not need to respond to these initial alerts. A follow-up page for Code Triage Manpower Pool Activated may be issued to rapidly assemble hospital staff for deployment as needed. Externs who are on the hospital campus will report to the Manpower Pool in the auditorium when the disaster is called. Externs may be deployed to any area as needed by the Incident Commander and/or Manpower Pool supervisor. Externs that have other duties still need to check in with the manpower pool but may be released to address those duties. 7

Fire safety To report a fire: Call 3333 If you identify a fire, remember RACE: Rescue: get patients, visitors, staff to safety Announce: activate fire alarm and call 3333 Confine: the fire by closing doors, never reopen a door Extinguish: use fire extinguisher if you can To use a fire extinguisher, remember PASS: Pull: Pull pin Aim: Aim hose at base of fire Squeeze: Squeeze handle Sweep: Sweep spray across fire Injuries If you are injured on the hospital campus (e.g. needlestick, fall, etc.) you are to report to the Emergency Department. Since you are not an employee of GCH your insurance information will be collected and your insurance company will be billed. Smoke-free campus Garden City Hospital and its associated facilities are a smoke-free campus. This means that smoking and use of tobacco products is prohibited throughout the campus. Also prohibited is smoking during a shift such that clothing or uniforms smells of smoke upon return. For patients who are smokers, resources will be available, including nicotine replacement products. Patients are not permitted to smoke outside the facility. Alcohol- and drug-free workplace It is the policy of Garden City Hospital and its affiliates to provide safe patient care according to prevailing standards and to insure that all of its employees and students are able to function properly and are not impaired due to the use of drugs or alcohol. The consumption, possession, distribution, sale, offering for sale or being under the influence of intoxicants, narcotics or other legally controlled substances while on Hospital property at any time is prohibited, unless the use has been prescribed and determined to be safe for use while performing their job function by the individual s personal physician. In the case of suspected impairment of a healthcare provider, the Vice President of Medical Education and/or the Chief Medical Officer should be contacted. Confidentiality Patients and staff members have an unquestionable right to expect all personal information about themselves, their family, and financial circumstances be kept confidential. Information about Garden City Hospital, its patients, medical staff, employees or suppliers, should not be divulged to anyone other than persons who have a need to know, or are authorized to receive such information. When in doubt as to whether certain information is or is not confidential, prudence dictates that no disclosure be provided without first clearly establishing that such disclosure has been authorized by appropriate supervisory or management personnel. This basic policy of caution and discretion in handling of confidential information extends to all electronic, written and oral communication for both external and internal disclosure. This policy applies to all employees and students when on duty or off duty. 8

Students should have a reasonable expectation of personal privacy in the workplace. However, for the Hospital to conduct its business, lockers and other spaces assigned to individuals remain the property of the Hospital and are subject to search at the discretion of the Hospital. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires healthcare providers to protect the integrity, confidentiality, availability and security of protected health information (PHI). Information that contains patient identifying data may not be released, transmitted or communicated in any fashion except where patient care of business needs necessitates such action and is directed with proper authority and is permissible by law. Violation of HIPAA confidentiality and security regulations are serious matters and may result in disciplinary action up to and including discharge. Key reminders include: PHI includes information in written, verbal, and electronic formats. HIPAA does not preclude healthcare providers from sharing information on a patient s status with their families or others, but it does require that the patient consent to the sharing of information. This should be documented in the medical record. Do not leave patient lists, dictations, diagnostic reports, logs, or other documents with PHI in public places. All such documents must be disposed of in a locked bin (available throughout the hospital). House staff may not access the medical records of any individual unless that individual is being cared for by the house staff. House staff may not access medical records of family, friends or fellow employees out of interest, as a favor, etc. It is permissible to make photocopies of medical records documents for educational use. If you are distributing handouts, make sure to remove all patient identifiers by blacking (or whiting) out names, MRN, etc. Once the copies are no longer needed, they MUST be disposed of in a locked bin (available throughout the hospital). Computer, internet and email use The computer system including the network and stand-alone computers, software, e- mail and any Internet or Intranet access is the property of GCH. All computer documents, including e-mail, voicemail, and online messages, are GCH documents. GCH reserves the right to monitor, access, print, and disclose computer documents for any reason including to investigate suspected misconduct, locate needed information pursuant to legal or governmental request, or to protect GCH s interests. Students are not permitted to use or download GCH-owned software for personal use outside of GCH. In an effort to avoid unnecessary system maintenance and viruses, the following activities are prohibited: Disconnecting/reconnecting computer lines and network cables Installation of any software or hardware on GCH s computer network without prior authorization from the IT department (Caretech) Charging or syncing handheld devices, including PDA s, MP3 players, etc. on computers in clinical areas 9

Use of the internet is limited to business use only. Students should not expect privacy with personal e-mail messages sent or received. Like all messages sent and received, the content and volume of personal messages may be monitored. Restricted use includes but is not limited to the following: Users are NOT permitted to utilize e-mail to solicit personal business or activities, such as selling personal items or soliciting for personal charities. Downloading applications and programs to a GCH computer is prohibited. Sending harassing or threatening e-mail to another user is prohibited. This includes, but is not limited to obscene and offensive material or obscene or abusive language in connection with GCH s computer network. Using GCH s computer network to harass other employees or members of the public, including derogatory remarks, regarding race, color, religion, age, national origin, disability status or sex. Making derogatory or defamatory remarks towards another person or remarks which could be construed as harassment, including sexual harassment. Using GCH s computer network to store or transmit unlawful material. Examples of unlawful material include child pornography, libelous and defamatory material, including material that disparages the trade of vendors, competitors, and copyrighted, trademarked, and other proprietary or confidential material without proper authorization from the owner of the rights thereto. Using e-mail to distribute chain letters is prohibited. E-mailing patient protected health information (PHI) outside the firewall to another health provider or other entity is prohibited, UNLESS permission has been granted by the HIPAA Security Officer. Removing, modifying, forwarding or destroying GCH files (e-mail or otherwise) is strictly prohibited. 10