Tips for Writing a good assessment and plan

HOSPITAL MEDICINE

I use an approach similar to one found in the  Intern Survival Guide shown below with minor personal modifications. Assessment and Plan: Start with a one-line problem statement or summary statement (See Dr. Strong’s lecture) __ year old M/ F patient with PMHx of...

ADC VANDALISM – admission orders

HOSPITAL MEDICINE, MNEMONICS

There are several mnemonics to help you remember how to write admission orders. The one i like to use is : Admit & D/C VANDALISM (i.e. ADC VANDALISM) Here’s the general idea: Admit to Med/Surg; Tele;  Intermediate (PCU);  ICU. Select/Write Attending...

SEPSIS mnemonics

HOSPITAL MEDICINE, MNEMONICS

Sepsis comes from Greek word meaning, to make rotten. Think septic tank. Sepsis is an infection (suspected or confirmed) plus two of the following: S-Sleepy, difficult to wake up, or confused: Altered Mental Status (any GCS less than 15) E-Expiring and inspiring too...

Sepsis Page

HOSPITAL MEDICINE, INFECTIOUS DISEASES

“Broad Spectrum antibiotics don’t mean Vancomycin & Zosyn. There is a thought process to it. You have to give antibiotics that are appropriate for whatever system it is that is causing the sepsis. Sometimes you don’t know. That’s when you...

Admitting a Patient in CERNA PowerChart

HOSPITAL MEDICINE

To admit patient in CERNA, Powerchart, go to: Orders > Search field > Type “Adm” in the search field. 1) Choose “Admit to Inpatient” to enter the order for where (the floor) the patient should be sent, e.g. to Acute, Intermediate,...