Student Rotation Guidelines

Michael Dick

Updated January 18, 2000

This rotation is divided up into three segments: Independent Reading or Physician Directed Assignments, Inpatient Services, and Outpatient Clinics and Office Visits.  By pre-arrangement any one of these may be eliminated.

I.                             Independent Reading or Physician Directed Assignments – Learn the major ways children are different from adults for the purpose of passing an exam.  Take advantage of the generous amount of time provided during this month to accomplish your reading.  Extra time will be provided if necessary.  THIS IS A SERIOUS AND EXTREMELY IMPORTANT PART OF YOUR ELECTIVE!!  Some suggestions to get you started:

A.                 Congenital Heart Disease (cyanotic and acyanotic), dysrhythmias, Rheumatic Fever, Kawasaki Disease

B.                 Lung disease caused by ventilation of premature infants and inability to protect an airway.  Cystic fibrosis, alph-I antitrypsin deficiency, RAD-Asthma.

C.                  Conjunctivitis, sinusitus, otitis, pharyngitis and retropharyngeal cellulitus, preseptal cellulitus, indications for PET tubes and other interventions, and suppurative lymphadenitis.

D.                 Hypothyroidism, 21-hydroxylase deficiency, juvenile onset disease, and ambiguous genitatlia.

E.                  Gastroesophageal reflux, malabsoption, inflammatory bowel disease, pancreatic insufficiency, encopresis, constipation, rectal fissures, hepatitis, and jaundice (direct, indirect, physiological, and breast milk).

F.                  Henoch-Schonlein Purpura, Hemolytic-Uremic Syndrome, Post Strep Glomerulonephritis, Renal Tubular Acidosis, Pylonephritis, Hydronephrosis, urinary tract infections, Vesicourethral refux, bladder dyskinesia, enuresis primary and secondary, epispadius, and hypospadius.

G.                 JRA, reactive arthritis, and SLE.

H.                Febrile seizures, congenital deafness, hydrocephalus, Arnold-Chiari malformation, meningocephalocele, spina bifida, migration abnormalities, and neurofibromatosis.

I.                  Viral and bacterial meningitis, cellulitus, HIV, ectoparasites such as head lice, internal parasites such as pinworms, vaccinations for specific infections, childhood exanthems and endanthems, omphalitis, balinitis, and posthitis.

J.                 Physiologic nadir, anemia, sickle cell anemia, ABO incompatibility, leukemia, Wilm’s tumor, and retinoblastoma.

K.                  Tibial torsion, femoral anteversion, metatarsus adductus, Osgood Schlauter’s, Slipped capital femoral epiphysis, AVN – avascular necrosis of the head of the femur, Perth’s, scoliosis, kyphosis, developmental hip dysplasia, and ganglion cyst.

L.                  Strabismus, amblyopia, delayed visual maturation, hyphemia, ptosis, and dacrostenosis.

M.               Atopic dermatitis, acne, mongolian spots, Café- au-lait, vulgar warts, and seborrheic dermatits.

N.                Tyrosinmia and PKU.

2.          Inpatient Services – In this instance how things are done are as important as what is done.  Mechanical skills are acquired by doing: admissions, discharges, transfers and daily case management.  (See formats of documents below).

1. On days when patients are hospitalized (almost everyday) please page Dr. Mike around 8 pm the night before unless he has already instructed you about the time you are to meet him at the hospital for rounds.  The answering service number is 480-5938.
2. E-mail: bratdiet@hotmail.com
3. http://www.med-web.com/pediatricspecialists
4. “Pre-rounding” on the inpatients at PV and having a basic plan ready is encouraged but not mandatory.  Depending on your level of experience and where you are in your rotation, it may be a good idea to have a progress note on the chart or one ready to be reviewed.
5. The computer terminal in the Doctor’s Lounge @ PV will give you an idea of the current inpatient census and labs.  Dr. Mike or Jen, the rounding nurse, will show you how to use the computer terminal to access important information.
6. After rounds, unless otherwise directed, call the office for further instructions at 483-0688.  The private line is 483-4625. 

3.          Outpatient Clinics and Office Visits

1. Acquire knowledge and skills for developmental assessment, anticipatory guidance, immunization schedules, routine screening tests, aspects of the history and physical exam particular to each age group.
2. Acquire a basic non-threatening approach to the pediatric patient.
3. Acquire plan of care and time management skills.
4. The Pediatric Specialty Clinic at Parkview will give you an opportunity to see pediatric problems not encountered in general pediatric practices.  It is held on Tuesdays, 7^th floor at Parkview from 8:00 am until 2:00 pm.

4.          Making your pediatric rotation a positive learning experience

1. On the first day of the rotation provide your pager number (if available), telephone numbers, and e-mail address to the office staff. 
2. Fridays are your reading day – TAKE ADVANTAGE OF THIS TIME.
3. The nursing staff is a VALUABLE RESOURCE.  Both their time and assistance is important to your success in an endeavor.  Please consider them assistant instructors and our time managers.  They have extensive experience in pediatrics.  It is a good idea to spend a day “rounding with them”.  If there is a contradiction between what Dr. Mike has instructed and what the nurses are asking (and it is not an obvious medical issue) – do what they ask. 
4. You have free access to Dr. Mike and PA Kim’s office space.  Please be prudent with the use of the limited space at the nurse’s station.
5. No student is expected to “PRODUCE” during his/her time during this rotation.  You are to learn, therefore:

1.            Do not be timid about asking for time off to attend to personal matters, but please try to do so in advance.  We schedule a lot of time around our students.

2.          You are responsible for a weekly review session with Dr. Mike to access your progress in reading assignment, history and physical examinations, and overall satisfaction with the rotation.

3.          You are responsible for making this a positive learning experience.  Don’t “let the sun set on a question”.

4.          Seek out resources at your disposal and the hospitals that the practice is associated with that will enrich your learning.  Brief “side rotations” are possible with colleagues associated with the practice. 

5.          Our patients invest a lot of money to come to see us and often have high expectations.  They deserve the best and it may seem like we are constantly checking up and repeating your actions.  However, our parents are used to students and very few will not consent to an initial exam by a student.  PLEASE respect their feelings.

6.          Learning a general approach to problem solving and approaching pediatric patients is more important than “being right” all the time.  We understand that if you all knew everything about Pediatrics, a rotation would be unnecessary.

7.        SIGN EVERY DOCUMENT YOU WRITE ON!!!!!

Documentation Formats

1)         Office Notes (sick visit):

Vital signs and Subjective/History

Started by the nurses.  This is the responsibility of the physician/PA!!  Important factors in general childhood well being should be reviewed: feeding, sleeping patterns, energy level, etc.  Remember: frequency, duration, radiation, onset, severity, and associations.  Parental perception is always important.  Eliciting significant information is our job not the nurses or the parents.  Physical Exam/Labs

Always include a brief evaluation: ENT, chest, heart, abdomen and extremities even if it is not relevant to the primary complaint.

Assessment

The most important part of the note is completed in outline format.  Be brief, stating only relevant information.  Make it legible.  A busy physician/PA/nurse has to read this in the future.  This is not a place for extraneous information.

Plan

Outline all interventions and instructions.  IF IT IS NOT DOCUMENTED IT DID NOT HAPPEN.  Ask open-ended questions to complete the visit.  Make sure the visit was satisfactory and document an understanding by the parents.

2)         Well child visits are your chance to learn about normal growth and development.  Special formats are available for each specific age group.  They are available if requested.

3)         Inpatient Daily Progress Note

Objective:  Trends and examples of vitals (including O₂ Saturation) for last 24 hours

Input: expressed as a percentage of maintenance

Output: urine expressed in cc/kg/hr

Physical Exam: often only the pertinent positives may be documented

Assessment/Plan: Clearly state the patients age and sex.  Then a ONE sentence statement of the problem, so that a busy physician/PA/nurse can pick up the chart and immediately know what is the primary problem at a glance.

Problem and system oriented outline then follows:

Example

1)          Pulmonary (system being addressed)

Dx (diagnosis): CXR shows right upper lobe infiltrate, sats in low 90s

Rx(treatment): albuterol nebs q2, O₂ at ½ liter via nasal cannula

A (Assessment): Reactive Airways disease with improvement

P (Plan): Wean O₂ to RA today keeping sats > 94, decrease albuterol nebs to q4

2)         Cardiovascular

3)         Renal

4)         GI

5)         CNS

6)         Etc

Everyone should end the note with some comment on:

7)         FEN (Fluid, electrolyte, nutrition)

8)         Psychosocial

Even if all that is said is that the patient’s intake is “adequate”

“No psychosocial needs are identified” OR “ the parents were appraised of the child’s status and expressed understanding.”

4)         Admission History and Physical – complete the form provided by office staff or by Jen, Dr. Mike’s rounding nurse.

Date of Admission

Date of Dictation

Medical Record Number

Repeat this information at the end of the document (if dictating)

Identification: Age, sex, and chief complaint

History of present illness (be chronological – remember frequency, radiation, onset, severity, associations).  Parental perception is always important.  Eliciting significant information is our job not the nurses or the parents.

Past medical history

Birth history (if relevant)

Previous admissions

Surgical History

Family history

Allergies/drug reactions

Immunizations/Childhood illness

Current Medications/Vitamins

Nutrition

Development/school performance – Daycare attendance

Psychosocial (living conditions, parents – occupation if relevant, siblings, smoking, pets, water supply, travel history, insect exposure, etc)

Review of Systems: pertinent positives ONLY

Physical Exam/Lab – Radiographic data

Assessment

Clearly state the patients age and sex.  Then a ONE sentence statement of the problem so a busy physician/PA/nurse can pick up the chart and immediately know what the primary problem is at a glance.

Then outline the other problems.

Often the assessment and plan is all that will be read of your note – this is where you spend your most time.

Plan

After speaking with Dr. Mike or someone from Dr. Mike’s office document on the form what will be done for the patient.  If dictating, read the admission orders in an outline form into the Dictaphone.  End your dictation with “This patient will be carefully followed by Dr. Dick.  Any further diagnostic and therapeutic interventions will be performed as indicated.”  Give specific examples if relevant.

5)         Discharge Summary (This is an example only, you will not be expected to dictate discharges)

Date of Admission

Date of Discharge

Date of Dictation

Medical Record Number

Discharge Diagnosis – Outline format (omit the admitting diagnosis if it has changed)

Procedures

Brief History Prior to Admission – Summarize Admission H + P in a few sentences

Hospital Course – Problem and system oriented outline then follows

Example:

1)          Pulmonary

2)         Cardiovascular

3)         Renal

4)         GI

5)         CNS etc

Disposition – Read D/C orders into Dictaphone (see below)

Send copies to all interested parties: especially referring physicians!  Often a call to the referring physician is also warranted!

6)         Discharge Orders

Discharge patient

When and with whom

Under what conditions - i.e. after seen and cleared by another service, after home heath care set up, after parents demonstrate understanding of some educational goal (i.e. nebulizer use, CPR), after adequate fluid intake is demonstrated (either nursing discretion or under parameters we establish), after a report is called (lab, xray, nursing assessment)

Discharge Medication - Exact Doses in cc (volume) and mg/kg

Discharge Diet -Only if relevant, Rarely Necessary

ALWAYS document some follow up! (Usually an office visit, at least some phone contact to update status).

Discharge instructions

Non medical interventions (i.e. mechanical GER measures)

Call Orders for parents (under what conditions they should present to the ED or call in for further instruction sooner than their follow up visit)

Always end your dictation of the discharge orders with “The parents were instructed to call with any questions and concerns not specifically addresses above”

7) Admission Orders

Several excellent formats exist. Please check with Dr. Mike on a case-by-case basis for acceptability.

8) Dictation PV

A) Dial Parkview 373-4000

B) Dial 8282 then the patient location number 2#

C) You will be prompted for a user ID. Punch in Dr. Mike’s number: 1929#.

D) Press 1 to dictate and 3 to listen to radiology reports

E) Work type number is next: admission (11), Discharge (14), Consultation (12)

F) Then type in a 6 digit patient number

G) Press #2

H) Begin to dictate.  A dictation card with all the telephone prompts is available from transcription.

I)Announce clearly whom you are, spell your name, provide our office  number and state you are dictating for Dr. Mike.

J) When dictation is completed punch in 9 to disconnect from dictation line – MAKE SURE TO RECORD THE JOB ID#  – provide this number to one of Dr. Dick’s staff.

K) Provide a copy of all dictation to referring physicians, my office staff, and the pediatric specialty clinic.

L) Sign all dictation.

M) Obtain a copy for your educational institution. Review ALL dictation with Dr. Dick after it is transcribed.

9) Dictation Lutheran

N) Dial 435-7571

O) You will be prompted for a user ID. Punch in Dr. Dick’s number: 1929#.

P) Work type number is next: admission (11), Discharge (14), Consultation (12)

Q) Then type in a 6 digit patient number

R) Begin to dictate.  A dictation card with all the telephone prompts is available from transcription.

S) Announce clearly whom you are, spell your name, provide our office  number and state you are dictation for Dr. Mike.  There is no dictation job ID # available at Lutheran.  Provide the date of dictation to one of Dr. Dick’s Staff.

T) Provide a copy of all dictation to all referring physicians, my office staff, and the pediatric specialty clinic @ Parkview

U) Sign all dictation.

V) Obtain a copy for  your educational institution.  Review ALL dictation with Dr. Mike after it is transcribed.

Note:  Anytime you are asked to see a patient in the hospital, please have a name badge or identification with you.  You are responsible for introducing yourself to the nursing staff and to patient family members.

Have Fun or else you are not doing this right!