For in-house patients, write a pre-op note the night before surgery to confirm that everything is in order for the OR.
For same-day admissions, you will be expected to write a brief, focused H&P. This takes place in the pre-operative holding area and you will be released from rounds by 7:00AM to evaluate the patient. Please respect your patient’s privacy and modesty when performing your H&P (i.e. speak quietly and draw the curtain). Some attendings provide pre-printed copies of the H&P. You should review the information before scrubbing in on cases. You should also take the opportunity to introduce yourself to the patient as a member of the surgical team working with a particular attending.
Cases do not always start at the scheduled time. There are cancellations, cases get bumped forward or backward, and cases are completed faster or slower than expected. Be prepared for this! Give yourself plenty of time, and keep a close eye on the OR board. Be considerate to one another. If you are finishing a case sooner than anticipated, page the student covering the next case so that he/she is not late. Even if you are not scheduled to cover a particular case, if you notice that the H&P hasn’t been completed, JUST DO IT!
Most elective patients have been evaluated in the clinic prior to being scheduled for surgery. You should copy pertinent information from the office chart to improve the accuracy of your H&P and to get a hint about what the case involves. This will guide your pre-op review. Please do not remove the actual office chart. Just make a copy of the pertinent info (i.e. H&P, previous op note, office notes) and hold onto it. Please be courteous to the office staff when requesting to see the charts.
OR Etiquette
When asked if you want to scrub in on a case, the answer should always be an enthusiastic “Yes!”.
Anything blue is sterile. Do not touch or come within one foot of the instrument tables.
Pull your gloves for each case and open them in a sterile fashion for the scrub nurse. If the scrub nurse isn’t in the room or you’re not sure what to do, Ask! Make sure there is a gown available for you. For added points, pull your resident’s gloves as well and introduce yourself by name to everyone in the OR.
Write your name followed by “MS3” and your resident’s name followed by “Resident” on the dry erase board in the OR before the start of each case. This helps the nurses keep track of who is in the room.
Help to transfer all patients to and from the OR. Take the stretcher out of the room after you help the patient over to the OR table, and retrieve it when the patient is emerging from anesthesia.
Help to fit the patient with venodynes, help with the foley catheter and patient positioning when appropriate.
Lectures and other student responsibilities take precedence over operative time. If you need to scrub out of a case to get to a conference or other important activity, always warn the attending prior to the start of the case and then ask again immediately before you scrub out. Offer to call one of your colleagues to scrub in for you if anyone is available. If you are not on call and the case is running late, please have the on call student page so that he/she can replace you in the OR.
Never interrupt an operation before asking the attending for permission to speak.
You will be offered the opportunity to perform technical tasks based on your performance and level of interest. The more you practice tying knots outside the OR, the more likely you are to succeed when the moment arises. Always practice serious tying with latex gloves on.
Write the operative note at the end of the case, and later in the rotation, volunteer to write post-op orders.
Elevator & Hallway Etiquette
Please be courteous of patients and protect their privacy. Not only is this professional behavior, it is required by law (HIPAA). Speak softly in the hallway when presenting; patients can often hear presentations from their hospital beds.
DO NOT discuss any patient cases when riding in the elevators.
DO NOT eat or drink during rounds. This is a hospital policy.
Make sure that you sign out or log out of EMR's prior to leaving a work station.
Postoperative Care
Except in rare cases, you will follow the patients you scrub on or admit from the ER.
Everyone deserves a post-operative note. This is the same format as an AM note and should be done about 4-6 hours after surgery, once the patient is settled in on the ward. Specific concerns to be addressed are post-op pain control, fluid resuscitation, DVT prophylaxis, and pulmonary toilet. Have your work, and the patient, checked by someone above you (usually an intern). You do not need to stay in-house until 8 pm to post-op your patient – just make sure you sign these patients out to the student on call.
AM Rounds
If you are scheduled to scrub on a 7:30AM case, wear scrubs to rounds. This will save you time. Otherwise, dress clothes are appropriate (what you would wear to clinic or conferences).
Morning notes need to be completed by the time we start rounds. Rounds will start anywhere from 6:00AM to 6:30AM during the week. You should photocopy your note for rounds, and you may read quantitative data from your note, but you should be able to recall your subjective and PE findings as well as your plan from memory. Please have the notes in the chart so that they may be reviewed by the residents and attendings.
On the weekends, AM rounds will begin at 8:00AM unless otherwise specified. There will be no afternoon rounds.
If you are unsure of the plan on your patient, do not complete this section in your note. Try the plan out on us before you make it part of the official medical record.
A patient’s disposition plan should never be included in your official charted note.
Never discuss a plan with a patient before it is presented before the chief and approved.
Never discuss pathology results with a patient.
All notes, regardless of how complex, should be limited to a single page. Leave some room at the end of your notes for the intern to jot a few words – this helps to clarify the plan. Also, leave room for the attending.
It is your job to insure that your daily note is signed by the intern - on rounds or immediately thereafter.
Present your patients clearly, formally, and concisely using accepted medical ease. “Positive” bowel sounds do not exist. Bowel sounds are present or absent, and are either normoactive, hypoactive or hyperactive. Also, a patient is not “nauseous” unless the very sight of them makes you retch. However, they are often “nauseated” after surgery.
Make every effort not to wake your patients before 5:00AM. This will not always be easy, but try to gather all of your data and write a skeleton note first, then do your exam and fill in your plan.
Because of the vast amount of associated data, ICU patients will take you longer to see in the morning. Give yourself extra time, and ask for help if and when you need it.
PM Rounds
The timing of afternoon rounds will be much more variable. Try to see your patients as often as possible in the afternoon to be prepared for rounds. You will usually have about a 15-minute warning prior to the start of rounds. We realize that if you have been in clinic or in the OR all day, you may not have time to see your patients. This is where you can really help each other out, while helping the team to run smoothly. If one of your colleagues is tied up in the OR, see his/her patient(s) and let him/her know what is going on.
If rounds have not begun by 6:00 PM and you are not on call, you may leave for the day.
Labs usually come back around 11:00AM. If you’re available, review all the labs on the team, including culture results. Let the intern know about any abnormal values on all patients – not just your own.
Pathology results usually take 3-4 days to come back. Keep checking for these. This is particularly important in cases where the pathology is in question or if the results impact upon treatment, management or prognosis.
