WARD INPATIENT SERVICE

INPATIENT EXPECTATIONS AND RESPONSIBILITIES

Senior Resident Goals & Objectives

Goal: Provide leadership and organization to the inpatient team.
Objectives:
1. Assign admission and consult patients to interns and students, promoting
continuity of care
2. Provide clear expectations to learners
3. Lead time efficient, educational, family centered rounds
4. Coordinate communication between subspecialty attendings and team
5. Maintain patient sign-out list for call team and intern assignment list for
HUC (including pm coverage for clinic/post-call interns)
6. Attend daily discharge planning rounds at 0730, meet with charge nurse
daily regarding admissions and discharges

Goal: Supervise the clinical care provided by interns and students on the PACC.
Objectives:
1. Directly oversee all clinical care of the sub-intern, co-signing orders and
notes
2. Provide oversight, leadership and support to interns
3. Review plan of care and orders on all new admissions and consults with
interns and students; encourage intern interaction with attending/fellows
for new admissions and consults
4. Assist and guide interns in developing time efficient strategies for organizing
and completing clinical work (calling consults, reviewing labs and studies,
writing orders, preparing discharges, and following up on results of
labs/studies after discharge)
5. Utilize faculty as consultants, updating with important clinical information
and asking for assistance in clinical management when needed
6. Respond to all pediatric Code 99s

Goal: Serve as the principal educator for the team, coordinating educational opportunities for
learners.
Objectives:
1. Schedule teaching time for the team
2. Delegate educational topics to students, interns and faculty
3. Demonstrate physical exam findings and clinical pearls on bedside rounds
4. Provide students with direct, constructive feedback, a safe learning
environment, input on write ups and presentations, and access to
information about their patients
Junior Resident Goals & Objectives
Goal: Provide family-centered patient care for patients with common pediatric signs,
symptoms, and diagnoses requiring hospitalization.
Objectives:
1. See and examine your patients daily prior to bedside rounds.
2. Review your patients’ notes, vitals, labs, studies, & MAR daily prior to bedside
rounds.
3. Develop plan of care for the day.
4. Prioritize work-entering orders, calling consults, following up on studies, etc.
efficiently

Goal: Understand the scope of medical knowledge needed to manage common inpatient
diagnoses and demonstrate the ability to acquire, interpret and apply new knowledge to patient
care.
1. Provide education and guidance for the medical students, giving them direct,
constructive feedback, a safe learning environment, input on notes and
presentations and access to information on their patient
2. Anticipate discharges by initiating discharge instructions and summary and
providing prescriptions to parents as early as possible
3. Attend teaching conferences and rounds
4. Read about your patients and share learning with the team
5. Complete educational checklist of common inpatient diagnoses.

Goal: Demonstrate effective communication skills with patients, families and colleagues
1. Prepare patients and families for bedside rounds. Serve as primary communicator
with family in room during rounds (unless followed by MS3). Keep family informed
of changes in clinical status or in plan of care.
2. Write a history & physical and systems or problem based plan of therapy on each
new admission
3. Write a concise daily note on each patient, emphasizing your medical decision
making and plan of care.
4. Complete detailed off-service notes for complicated patients.
5. Complete discharge summaries at discharge and route to PCP
6. Communicate daily plans with the nurses
7. Document changes in clinical status whenever they occur
8. Communicate with senior resident with updated patient information
9. Communicate key medical information to the nighttime team during handoffs and
provide thorough sign out to the incoming intern at the end of your rotation
Student Expectations:

Sub-interns
 Follow 4-6 patients at one time. Discuss with the senior resident which pts you should
follow.
 Function as much as possible like an intern (see above intern expectations) but without
MS3 involvement on your pts.
 Review daily exam and notes with senior resident (senior resident will examine your
patients and cosign notes)
 Present your pts in rounds.
 Complete discharge summaries within 48 hours of discharge, ideally the same day. See
dictation guidelines for details.

Third year Medical Students

 Follow 2-4 patients at one time, assigned by PL3. You will be the expert about your
patients. Your patients should regard you as the primary caretaker.
 Write a history and physical on patients you admit and place in chart within 24 hours.
Assessment should include a differential diagnosis with the most likely diagnosis first.
Plan should be by systems or problem.
 See and examine the pts you are following everyday
 Review all orders, consults, treatments, labs and imaging results over the last 24 hours
on your patients
 Present your pts in rounds according to presentation guidelines.
 For retrieval of urgent imaging results, coordinate with your team when requesting the
results to avoid multiple phone calls to the same radiologist.
 Go with your pts to their procedures (imaging, operating room, etc) after approval of
senior resident and radiology or surgery attending.
 Provide the parents with the team structure (attending, resident, student) and serve as
the primary communicator to your patient’s families on rounds and throughout the day.
 Anticipate discharges by initiating and sharing EPIC Discharge Instructions, as well as
writing prescriptions.

Attending Expectations
The attending is directly responsible for the care provided to all of the children on his/her
service. She is also a teacher, a mentor, and a consultant. Attendings should:
 Review histories written by residents and students.
 Empower the PL3 to manage the team.
 Review or perform physical examination as necessary.
 Cosign resident notes.
 Contact private primary care providers regarding admission, updates and discharges.
 Attend bedside rounds
 Approve discharges of patients
 Provide feedback to team members
ADMISSIONS, CONSULTS, and DISCHARGES

Incoming Admissions:
 Transfers from outside ED/Hospital/Clinic come to the attending through the transfer
center, 4-7000. The attending will contact the senior resident with the details. The HUC
should call the senior when the pt arrives to the floor.
 Admits from OHSU ED will be called to the senior resident by the ED resident. For Gen
Peds pts, the ED attending will also call your attending (true for OHSU and Kaiser).
Maintain collegiality and professionalism (Don’t try to deflect admits). Simply ask if the
ED has contacted your attending.

Admissions on weekdays will be "worked-up" by the ward team to which they are assigned until
5:30 p.m., and by the night call team thereafter. On Saturdays and Sundays all admissions are
worked-up by the weekend call team.

Identifying and Contacting the Attending Physician

Discuss the preferred communication about admissions with your attending. Contact the
attending with any questions or concerns that you have about a patient. If you are worried, we
want to worry with you.

The name of the attending physician must be written in all admission and transfer orders (the
latter includes service to service and place to place, e.g., PICU to floor). If the orders do not
include the name of the attending, the orders cannot be activated until the name of an
attending is provided. EPIC should reflect the proper attending for each patient.

Pediatric Consults
When a General Pediatrics consult is requested on the wards, the patient should be assessed,
staffed, and followed just as a new admission would be.  The attending should be notified
promptly that there has been a consult requested.  The PL-1 (or senior) should review the
history, examine the child, review the consult with the senior resident and subsequently staff
with the attending.   After the case has been staffed with the attending, the service requesting
the consult should be called and the recommendations should be communicated verbally and in
an EPIC consult note. 
 
A consult should ALWAYS be put on the list for the day team to know about them, and should be
assigned to an intern to follow.  The team can decide at a later time if they feel it is appropriate
to sign off.
 
In the event of a non-acute consult called late at night, you should ask the requesting service if
they think it’s appropriate for the consult to be staffed the following day by the attending.  If
they are ok with the attending staffing it the next day, you may complete your consult, add the
patient to the list, and staff with the attending the following morning.  
Discharges

Anticipate discharges by preparing necessary paperwork (instructions, discharge summary,

prescriptions) in advance. Make an attempt to provide discharge prescriptions to parents the
day prior to discharge to be filled at the DCH pharmacy as many pediatric formulations are
difficult to obtain at local pharmacies. Notify the attending of any “pre-rounds” discharges that
may be appropriate to see and discharge prior to bedside rounds.

Interns/sub-interns are expected to follow pending cultures/lab results on their discharged

patients unless alternate arrangements are made with the PCP, subspecialist, etc.

WARD TEAM SCHEDULE

(subspecialty rounding time TBD at time of document completion)
Please note that on-call residents are not permitted to arrive prior to 0700 on their call day so
as to be able to attend noon conference the following day without violating duty hours.

Pre-0830 Senior Resident:

-Receive sign out from night float (NF)
-Meet with Discharge Planner
-Delegate patients to students/residents and provide who’s who list to
HUC(if not done by NF prior to sign out)
-Notify attending of patients who may be discharged prior to rounds

Interns/students
-Receive sign out from NF or on call intern
-Pre-round/work-rounds on patients, examine patients, review chart,
formulate A&P, start notes, prepare bedside presentations. Medical students
and residents should review plans together.
0830-0900 Morning report
0900-1100 Bedside/Teaching rounds run by the PL3. Interns and students present in the
patient rooms, and a plan is formulated for each patient. All patients should
be examined by housestaff prior to work rounds. Attending will examine
children during rounds.
1100-noon Team completes am work, Attending and students gather at 11:30 as able for
teaching. Post call/clinic intern signs out to covering intern.
Noon-1pm Noon conference
1-5pm Admissions and other ward work are the responsibility of the remaining
residents for floor teams.
Weekends/Holidays on DCH Inpatient Service
Expectations of On-call/Post-call Residents:
 Friday Progress Notes need to indicate long range plans to assist cross-covering
residents on the weekend. Paperwork should not be left to the weekend team.
Complicated discharges should be neatly coordinated prior to the weekend if at all
possible.
 On weekends and holidays, pre-round on all General Pediatric and Subspecialty patients
by 0900. Facilitate discharges prior to rounds when appropriate.
 Senior resident assign weekend assignments to residents and students and will lead
weekend rounds in conference room. Subspecialty, Kaiser attendings may join sit down
rounds. OHSU hospitalist will run the list with the on call team after rounds.
 After 0900 rounds, residents will finish patient care.

DOCUMENTATION
 All admissions need an H&P documented by a resident
 All daily notes must have a physical exam and plan of care for the day documented by a
resident
 Notes should reflect thoughtful clinical decision making, and should not be a 3 page list
of vitals, labs, studies, medications, followed by an outdated plan that has been copied
and pasted from the day before.
 COPYING OTHERS WORK IS PLAGIARISM AND FRAUD AND WILL NOT BE TOLERATED—
this includes, but is not limited to H&Ps, progress notes and consult notes
 Notes should be completed by noon
 In addition to daily notes, you will be expected to document:
 Event notes documenting changes in patient status or extensive interaction with
pt/family. The note should contain pertinent vital signs and/or physical exam
findings, and any new laboratory data as well as your assessment of the patient and
your new plan.
 Transfer notes for any child transferred from the ward to an ICU or other service
area or vice versa.

COMMUNICATION & ROUNDS

Bedside Rounds
Purpose:
 To create and enact plans to deliver high quality family-centered care for our patients
 To communicate the daily plan with the family and the nurse
 To provide PL1- directed informal teaching and physical exam findings
 To teach MS3’s how to present new and old patients.

Sign-Out Rounds
Communication failures are the leading cause of preventable medical errors. Effective handoff
communication is crucial! Sign out rounds are intended to:
 Communicate key clinical issues regarding the current patients in order that the
overnight team may adequately prepared to safely and effectively care for the patients
on the service
 Discuss upcoming admissions