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Surgical internship demands efficiency and neurotic attention to detail, 2 often opposing modi operandi. As the workhorse of the inpatient surgical team, you will need to perfect both. Toward this goal, we recommend you do the following:

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  • Develop a system. Develop a system—for patient care, daily rounds, whatever—and stick to it. If you follow your system, you will be able to work more efficiently, organize the chaos of the day, prioritize tasks and information, catch things you otherwise would have missed, and, most importantly, keep your head on your shoulders when others around you are panicking, for example, in the middle of a chaotic code. You will become a better doctor, and your patients and colleagues will benefit.
  • In this chapter, we provide 1 example of a systematic approach to patient encounters and note writing. Patient assessment and oral and written communication are grouped together because all 3 processes are integrally related. A written note is simply the end result of organized and thoughtful patient assessment.
  • Understand that the purpose of a note is to communicate pertinent data, impressions, and plans with other members of the care team. A note is not just useless paperwork. Nor is it an arena to show off esoteric medical knowledge. Your notes will become a vital line of communication to other residents, attendings, nurses, and consults, and your handiwork will either facilitate or hinder patient care. You must learn how to write a useful note quickly for every situation that arises: admissions, consults, daily rounds, postoperative checks, acute events, and procedures. You do not need to adopt the exact approaches and templates presented in this chapter. But you must remember your purpose. And you must make and stick to a system to stay organized, thorough, and efficient.

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General Approach

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Whether admitting a patient from clinic, fielding a new consult, or assessing an unstable postoperative patient, our general approach is the following:

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  1. Right now, before you start internship:

      1. Program your brain:

          1. Ingrain the basic H+P and SOAP formats. Make it second nature. Be able to ascertain, process, and present complicated patient histories in minutes, in the right order, with all the right information. Soon, you will need to do this countless times per day under far less favorable conditions than medical school (picture your pager going off every 30 seconds, impatient colleagues, difficult families, crashing patients, etc). To get it right, every time, you need to learn and stick to a system.

      1. Make yourself some templates:

          1. Make yourself some skeleton note templates (see examples, Figures 5-1 to 5-4) and store in a readily accessible e-mail or computer location.

            Figure 5-1.Graphic Jump Location

            Sample template: admission/consult H+P. Highlighted areas indicate tips and fields to be filled in by the writer.

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