Intern Survival Guide :. ED EDITION. Outline. Introduction Schedules FirstNet Where things are When things happen Charts. Orders Consults Admissions Discharges Procedures. So you’re starting the ED….
Brief HPI, PMH and physical exam.
Tip: Note the PMD somewhere on your H&P form.
Sign, date and time at the bottom.
ED, like all of medicine, is all about documentation.
You will document any change in patient status, reaction to medication, conversation with a PMD or consulting physician, etc.
Document anything that you would want to know if you were a consulting physician looking at the chart for the first time.
When a patient leaves the ED – whether it is to home, to the OR, to 11N, or to somewhere else – a disposition form must be filled out.
Fill out everything except for diagnosis and billing – the attending will take care of those – and sign at the bottom.
This will be reiterated multiple times, but if you are discharging a patient from the ED, tell their nurse.