Internal Medicine Resident Handbook

- Outpatient First Edition 2013-2014

Editors Alejandro Moreno M.D. Celina G. Mankey M.D.

Authors Payas Vasanth M.D. Gayathri Nanja M.D. Benjamin Salgado M.D. Karthik Mekala M.D.
1

Table of Contents
1
1.1 1.2

Specialty Clinics ..................................................................................................................... 3

Schedule ............................................................................................................................................ 3 Resident Responsibilities .................................................................................................................. 3

2
2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

Continuity Clinics .................................................................................................................. 7

Intern Responsibilities ...................................................................................................................... 7 Referrals: ........................................................................................................................................... 7 Continuity/Firms ............................................................................................................................... 7 Pain contract...................................................................................................................................... 7 Referral Log ...................................................................................................................................... 7 Procedures ......................................................................................................................................... 7 Whos who ........................................................................................................................................ 8 Clinic Resident .................................................................................................................................. 8

3 4

Dress Code .............................................................................................................................. 8 Contact Information .............................................................................................................. 9

1
Days

Specialty Clinics
Clinics Cardiology Timings 8:00-12:00 Loca tion PBC Preceptors Seton Heart Institute- Dr. Roach/ Dr. Hayes Drs. Pandey/ Malik

1.1 Schedule

Hem/Onc Tuesday

8:30-12:00

POB

Clinic note for follow up should include the following: Pertinent complaints / progress since last visit Labs, Imaging Brief review of systems Physical exam Medication list Assessment and Plan Sign and date Include time frame for follow up Fill in the lab slips, Radiology slips, Billing sheet Clinic note for a new patient should include the following: Detail history Past medical/ Social/ Surgical History Medication list ROS Physical Exam Lab/imaging review Assessment and Plan Sign and Date Include time frame for follow up After discussing the case with the preceptor and discussing plan with the patient ask the patient to be seated in the waiting room and place the chart in the nurses' station for discharge. Do not forget to write prescriptions or lab slips if needed. Keep an eye on time that patient is waiting for appointment. Let your preceptor know when you present if patient has been waiting for more than 30minutes already to speed up process. Keep clinic notes organized. Clinic notes are a medical document that helps you and other doctors organize and most important organize relevant information. Clinic notes should be: Written with clarity. Handwriting is important. Summarized. Notes must contain only pertinent information. The chief complaint will help you filter some date that may not be so important Contain relevant information about: past medical history, past surgical history, allergies, date of last screening, immunizations, social history.

Monday

Wednesday

Gastroenterol ogy Nephrology

8:00-12:00 8:00-12:00

PBC POB

Thursday

Endocrine Allergy/Imm unology

8:00-12:00 13:00-17:00

PBC POB

Drs. McHorse/ Mank Dr. Maidment/ Dr.Nader Dr.Kulkarni/ Taylor/ Kumar Dr.Peters Dr. Uchiyama PC3A service Dr. Shah/ Perret/ Harford/ Morrison/ Heinz/ Shapiro

Rheumatolog y Pulmonary (every other Friday) Friday

8:00-12:00 8:00-12:00

PBC PBC

PBC: Paul Bass Clinic lower level UMCB POB: Professional Office building

1.2 Resident Responsibilities

Recommend getting to clinic by 7:45 A.M. Clinic starts sharp at 8:00 A.M. Endo and hem/onc have 30 minute lecture before clinic begins. Most other specialties will start this as well. Charts start lining up in the chart holder (resident room) depending on the time of check in. Always pick up the first chart. Review notes from prior visit if it is a follow up patient. Get to know the history and items to follow up example labs, imaging. If it is a new patient, review the referral notes and take a detailed history and physical.

Primary Preventive Health PBC:

USPSTF adult cancer screening recommendations:

21 to 65 years Pap smear every 3 years 50 to 75 years Annual FOBTs 40 to 49 years individualize decision Or Sigmoidoscopy every 5 years with FOBT every 3 years 50 to 74 years Annual or biennial mammogram Or Colonoscopy every 10 years Or 30 to 65 years Pap smear and HPV testing every 5 years No screening for: > 65 years with adequate prior screening and not high risk; Hysterectomy with removal of cervix and no prior highgrade lesion. No screening for: > 85 years No screening with: CT scan or double contrast barium enema No screening with: MRI or self breast examination; insufficient evidence to use clinical breast examination

CERVICAL CANCER

COLON CANCER

BREAST CANCER

High risk patients Start before age 30 or at least 10 years prior age when relative diagnosed with breast cancer

OTHER CANCERS

No routine screening recommended

USPSTF screening for common medical disease:

Women Men 65 to 75 years with HTN and smoked Interval Once in lifetime Not defined Not indicated 1st trimester Every other year All >35 years 20 to 35 if CAD risks Every 5 years Method Abdominal ultrasound CAGE questionnaire CBC, iron level BP measurement Non-fasting T.Chol and HDL

ADOMINAL AORTIC ANEURYSM ALCOHOL ABUSE IRON DEFICIENCY ANEMIA HYPERTENSION LIPID DISORDER

No indication All patients >18 years All pregnant All patients >18 years All >45 year 20 to 45 years if CAD risks All patients >18 years

DEPRESSION DIABETES MELLITUS HEPATITIS C HIV OBESITY OSTEOPOROSIS

Not defined Not defined Once in lifetime Not defined Not defined Once in lifetime

Various tools Fasting glucose or Hg A1C Serology Elisa test BMI measurement DEXA scan

All patients with sustained BP >135/85 or risk factors (i.e. Latino, FMHx, and obesity) All patients born between 1945 and 1965 13 to 64 years regardless of risk factors All patients regardless of age All >65 years Not indicated

ADA preventive health for diabetic patients Diabetic retinopathy: annual retinal examination Diabetic foot: annual foot exam with a 10-gr monofilament plus ankle reflexes Diabetic nephropathy: annual microalbunim measurement Diabetic control: quarterly Hg A1C if uncontrolled or therapy changes Lipemic control: annual fasting lipid profile HTN and obesity: BP and weight measurements with every visit 6

Continuity Clinics

2.4 Pain contract

A pain contract policy was recently enacted for the prescription of narcotics (Norco), as well as Tramadol, benzodiazepines, SOMA. (Residents can prescribe morphine and dilaudid in the inpatient setting, but cant do it in the outpatient setting as we do not have triplicates.) This system was enacted specifically for patients requiring long term (>3 months) pain management. This is not for patients acutely being treated for pain. Process: 1) The patient needs to have a documented reason for pain. 2) They need to complete a pain intake survey and assessment packet (located on top of chart rack). 3) A random urine drug screen must be completed before a contract is signed, which may be repeated at any time. If they are positive even for cannabis, the pain contract is void. 4) A determination needs to be made on the exact dosing and frequency of the medication. 5) The actual blue contract needs to be signed by the patient and physician and copy placed in chart and scanned to High Alert Program (Clerk will do this) 6) This process is lengthy, and hence may take a separate visit to complete. 7) Reevaluate policy every 3-6 months and void contract if medication no longer needed or warranted clinically.

2.1 Intern Responsibilities

When you see a patient in Paul Bass Clinic or the VA, you are their PCP. That means, managing the complete picture: addressing present complaints, managing chronic diseases, following up on any specialty consults that are necessary, and keeping them up to date on health maintenance according to guidelines. When you come to clinic, review the chart and Compass records of your given patient. Document your findings in the note, along with an assessment and plan to the best of your abilities. Complete the problem list and make sure to meet the preventive health measures. You will then present the case to your attending, and can discuss any queries you have in terms of difficult medical or social situations. Complete the billing sheet, med reconciliation, lab orders, radiology forms, and prescriptions for the patient.

2.2 Referrals:
If you are in need of a consultation (from specialty services) there are referral packets located on the wall with specific pre-referral labs, and criteria for referral. Be aware that referral to specialty clinics is often a lengthy process so if the need for the referral is urgent, you may need to admit the patient (discuss this with your preceptor first. If you refer to ED, you must call ED triage physician 324-9994 first to give pass-off). You can track the status of your referral on the PBC referral log which can be reached by clicking on the corresponding icon located on the desktop of all the computers in the clinic (SharePoint site). This will provide you with information of the status of your request, date of an appointment, and extra studies that may be necessary.

2.5 Referral Log

Electronic system to track and organize imaging and specialty referrals. It improves quality of patient care in continuity medicine clinics. Each computer at PBC has a desktop icon labeled "Home PBC Internal Medicine". Double click on this icon and you will be prompted for a password. Enter your Seton login name and password. After logging in, double click on the "PBC - Referral Log" tab which will open up an Excel sheet. The sheet lists the names of the patients, MD referred, date of referral, status, and comments regarding progress of referrals.

2.3 Continuity/Firms
The residents in clinic are divided into firms composed of a 1st year, 2nd year and 3rd year. Between the residents in each numbered firm, a group of continuity patients is maintained. When you pick up a chart, do confirm the patient is in your firm, and if not, please make note of this so the patient can be rescheduled with a doctor from their firm on their next visit. This is to ensure continuity for patients when dealing with residents with fluctuating schedules as PCPs. Each chart has white label on inside of front cover that has FIRM number for patient.

2.6 Procedures
As PCPs, we perform womens health services in the clinic. Be aware that you must be signed off and observed by an attending before performing Pap smears on your own.

MAP vs. PAP MAP is the Medical Assistance Program and PAP is the Patient Assistant Program. When prescribing for your patients, you have to be aware of what medications are covered on MAP and which are covered by PAP. If your patient requires a medication that is only covered by PAP, the prescription will need to be signed by an attending, and must go through an authorization process. As a general rule, medications and refills are generally cheaper for patient if they are obtained in a 90 day supply. Avoid this for pain meds, because the patient should be re evaluated every month. Remember to prescribe insulin supplies (strips, syringes, lancets) for your diabetic patients. There are preprinted prescriptions you can use for this.

2.7 Whos who

Shereka Houston Cheryl Groot Case Manager. Assist with referral process, insurance authorization, PAP, difficult social issues, chart checks. Social Worker. Assist complex social situations, psychiatry issues, community resources, counseling. Works closely with psychiatry clinic. Assist with scheduling, locating patients to clinics, financial. PAP coordinator Spanish Interpreter Nursing supervisor RN Clerk

Chasity Shugart

Refills of patients followed up in PBC. Clinic resident should authorize or deny the refill requests sent over by pharmacies. The chart will be attached to the request so almost always you need to review it. Sometimes, you may receive forms for PT, or disability that need to be completed. - REFILLSYou must review the chart before completing a refill for any patient. Some patients may be from specialty clinics but they see one of our NPs regularly for primary care or the patient may need that medication urgently. Do not deny any medications before reviewing chart carefully. You will be given time to do this at the end of every session. - You may encounter some refill requests which you may need to deny, like narcotics. Please read the pain contract, and advise the patient to come in for an appointment with their PCP. Respond to pages from the lab or micro about critical values of patients seen in Paul Bass clinic, primary or subspecialty. You will have to find out who ordered the test and try to give them a call, and if it is a concerning value, you may have to call the patient to come in to the hospital. Use compass and recent lab data to rule out expected lab results. For e.g., thrombocytopenia in patient with known cirrhosis

Dress Code
Clothes must be clean, neat and in good condition with no obvious stains or tears. This includes your WHITE LAB COAT. Physicians must maintain clean personal hygiene. Physicians are NOT allowed to wear scrubs unless they are on call for ICU or are on night float rotation. All physicians on consult services, wards, hospitalist, elective and clinics are expected to be in formal clothing. Formal Clothing DOES NOT include BLUE JEANS. Formal Clothing DOES NOT mean fancy or revealing clothes (just normal/daily wear clothing is considered appropriate). Please consider that you are acting as a healer and health mentor in the eyes of your patients and therefore you should try to dress accordingly. No sandals or open toe shoes.

Chris Grybzel Catalina Juarez Cynthia Rangel Traci CortesStephanie Penn Christy Featherson

Medicine Clinic Preceptors Monday Tuesda Wednesd y ay Dr. Dr. Dr. Laviolet Corak Laviolette te Dr. Dr. Salib Dr. Coats William s

Thursda y Dr. Laviolet te Dr. Maxwel l

Friday Dr. Moren o Chiefs

2.8 Clinic Resident The clinic resident is responsible for the following tasks: 8

Contact Information
80072 80087, 80088 70073 80076 80082

Paul Bass Clinic Resident Room Front Desk Charge RN (Traci) Case Manager (Sherika) Social Worker (Chasity)

Internal Medicine Coordinators 512-324-7863 Tommie Starkey 77563 Mike 77563 Darleen Chief Residents Amrew AlAhmed PayasVasanth

Cell-phone: 803-295-0155 Email: amrew84@yahoo.com, aalahmad@seton.org Cell-phone: 703-577-8706 Email: payas.vasanth@gmail.com, pvasanth@seton.org