Rounds

• Sign out - pay attention, be courteous about getting your night-time counterpart out by 6 AM at the very latest. They should not be calling you at 6:05 to give signout. Transfer your own pager to yourself.
• Check with your chief about how they want their list made. Vascular report with the I/Os and labs written on it is always safe. 
• Patient Report → 'Vascular Surgery Rounding Report' is most clutch...will print vitals (mostly), abx (mostly, minus antifungals), heparin/lovenox, diet
• Patient Report → 'Pt list portrait' is most bare bones
• Patient Report → 'Rounding report' is the Bible. Every piece of information is on there (meds, labs, etc). Some people like it but it's a lot of paper!!!
• Print → 'Handoff' is a slightly more concise version of the Bible. I like this a lot for transplant
• Print → 'Current List' gives a 'face sheet' that is helpful when you have a ton of patients and need them sorted by bed/name on one page
• Show up early enough to get sign out, and get numbers (probably by med student) before rounds
• Pre-rounding on patients is not expected, just make sure you thoroughly chart check, know the overnight events, and plan for the day.
• Most services - you are expected to present patients during AM rounds (or the medical student will present the patient(s) he/she is following)
• Presentation format: quick one liner, overnight events, vital signs, I/O, relevant labs, assessment/plan.
• Always try to have a plan :)
• Order of operations - sorted by most important
• Write orders, with most time-critical ones first
• CT scans, PICC line requests, diet. Should pretty much always make imaging orders stat...it's dumb but unfortunately that's what you gotta do
• If you order a truly stat study, best to call radiology soon after and ask for it to be protocoled, and let the nurse know you're expecting this study soon so they can also follow up with the radiology techs
• Just because you order something doesn't mean it's going to happen. Always plan to follow it up (call the nurse, etc).
• Call consults
• At minimum include name, MRN, call-back number. It's nice if you can include a brief summary of the question
• Just because someone recommends something doesn't mean you have to do it! You are still the primary.
• Discharge people
• Anticipate discharges early!!! Always keep your case manager in the loop. Especially: need for home IV abx, home TPN, rehab (check the PT/OT notes), inability to do wound care at home, etc...
• Before 2 PM - renew TPN! Do it early before you forget.
• Notes
• PM rounds - if your chief is unavailable/operating, it's always appreciated if you go solo round and then update them in the OR. Always feel free to come into the OR and update. But if it seems super stressful and your update isn't an urgent matter, wait for it to calm down.

Prescriptions

• Most of your seniors will be able to e-prescribe but lots will probably still ask you to write paper scripts. Since these don't have your name on them, if you mess them up, someone else deals with the call from pharmacy.
• These calls are just an inconvenience for the residents, but they can represent a major barrier to your patient's care.  It is not uncommon for patients to be driven hundreds of miles from Stanford, only to find that their local pharmacy won't honor a mangled prescription for pain meds just before closing time, and the mistake can't be rectified until the morning or weekday.  None of us wants to be the reason why a patient is suffering.  And believe me, your attending will not be amused, nor will the resident whose pad you are using. 
• ICD-10 code: G89.18 = 'post-op pain'. G89.11 = 'post-trauma pain'. This should cover you for most. Write it in the top left of the script.
• Write: Name, DOB, check gender box, and write MRN. You don't actually need to write the address/phone number.
• Do not deviate or remove anything from this format. Write out the number and spell it. If you have to cross something out, just start a new script.
• Oxycodone 5 mg tabs. Take 5 mg PO q4hrs prn pain. Dispense #10 (ten) tabs. No refills.
• You can use one range per form -- either # of tabs per dose or frequency of doses -- but not both.  For example: 
• "Take 1-2 tabs PO Q4 hours PRN pain" -----> works
• "Take 1 tab PO Q4-6 hours PRN pain" -------> works
• "Take 1-2 tabs PO Q4-6 hours PRN pain" ------> wailing and gnashing of teeth.
• Do NOT write for ranges in the amount dispensed.  For example, do not write "Dispense 75 -100 tabs."  
• Check the boxes: relevant range (eg. 1-24). Units means 'tabs, mL, etc.'. Refills: write '0'/'zero', and check the NR box. Initial. Yes, this is redundant but please do it
• Cross out the other two slots. Don't try to write more than one narcotic (or benzo) per prescription; some pharmacies just won't let you do this, whatever your little pad says. 
• It's good form just to let a resident know that you've stolen scrips from his/her intern and ask permission. 

Discharges

• Most services will have a clinic scheduler/coordinator that you should message in Epic when you're discharging a patient.
• Include brief summary (post-op distal panc/splenectomy, uncomplicated hospital course, drain is staying in, please follow up in 2 weeks). If they need labs/imaging before clinic, include that so they can make sure it happens
• When in doubt, include a referral back to the clinic (e.g. general surgery, GI/onc for all colorectal/surg onc, etc.) so that someone will call the patient to make their appointment.
• Be conscientious about med recs. Don't just hit 'resume all' without looking at stuff. Did you do a bilateral nephrectomy and now they don't have any kidneys? They probably don't need their ACE inhibitor anymore!
• Get in the habit of double checking the pharmacy w the patient/nurse before discharge. Changing pharmacies after you prescribe everything is a special hell of its own.

OR

• How to see what cases you have
• 'SDS', then add the attendings you want. I'd make a separate list for each service, make the time interval 'T' to 'T+7' (for cases for the upcoming week) and save that.
• If you have a first start case, try to check-in the patient before rounds if they are there
• White - patient not in house yet
• Orange - patient in the waiting room, not ready to be checked in
• Yellow - patient in pre-op, ready to be checked in
• Brown - patient check-in complete
• Green - in the room
• If you let the circulator know early that you'll be in the case (check in with them beforehand, or you've been in the room for the prior case), if they add you to their computer thing then you can get a Haiku notification for when they get in the room.
• Make sure consent is there, pre-op orders are in, H&P interval is put in, and yellow form checked
• When in doubt, all you need is 'antibiotics per preference' and 'SCDs'.
• When in doubt, don't give SQH. They can always give it once they're on the table. Don't give if it's a liver surgery, or if there's a chance that someone might want to put in an epidural.
• Don't assume the pre-op nurses will have asked all the relevant questions. Always, always ask for yourself: correct consent, last time they took anticoagulation/aspirin, recent illnesses. If any of the answers concern you, let the anesthesia team and/or your team know EARLY. Things get a lot more complicated if they've already gotten their sedation...
• Images
• If there's relevant imaging, try to bring it up on the OR computer with the biggest monitor. Open it up in Centricity/ICS7/whatever program they're using now (not the linked PACS from Epic)
• If you have no idea where the tumor is, use the radiology read (3/257 means Series 3, slice 257) to guide you.
• Op note
• Usually you do the brief op note and the attending/chief resident does the operative report. At Valley for small cases you'll do the op report.
• If you forget to ask anesthesia about fluids, it eventually gets charted in I/O, or 'please see anesthesia records' always works, not that I actually know what or where the anesthesia records are).
• In the brief op note, write anything that might be relevant for someone who needs to look before the op report is done (which drain goes where, relevant complications). "Please see operative report" does not suffice and is fairly useless/not the point.
• To prepare for case, some tips:
• Operative dictations is exactly what is sounds like. Read it to prepare for the case, or copy it in for your op report.
• SDS the attending for the last month or so, and click on a past similar case and read the op report. Then you can figure out if they like Hassan vs. Veress, what ports they use, how they like to position.

Clinic

• Cali is laid back but I would at least wear clinic clothes...tie optional...but scrubs might get you a look.
• There will be a paper list of patients somewhere (usually by the attending). Initial next to the patient you're going to see
• New patients generally have a stack of records printed out for you to pick up and review
• If there's path/imaging available, generally have that result up for the attending to look at