Internship Manual - Pages/Templates/homepage.dwt

BLUEFIELD REGIONAL MEDICAL CENTERIntern and OGME-1 Manual

Document Owner(s)Project/Organization

RoleSignature

Ronnie Martin, DO, FACOFP-dist

Director of Medical Education

Intern Manual Version Control

Version

Date Author Change Description

1 3/23/07 Dawn Stull New

2 8/23/07 Dawn Stull Review/Revised

3 6/13/08 Dawn Stull Reviewed/Revised (3.1)

4 01/30/10

Reviewed/Revised

Note The content of a manual does not constitute nor should it be construed as a promise of employment or as a contract between Bluefield Regional Medical Center and any of its employees.

Bluefield Regional Medical Center at its option, may change, delete, suspend, or discontinue parts or the policy in its entirety, at any time without prior notice.

OMNEE is a proud sponsor of the Bluefield Regional Medical Center.

Effective 2/23/10Intern ManualLast printed 3/4/2009 9:24:00 PM

Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual

is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future

residents.

Intern / OMGE-1 Manual

TABLE OF CONTENTS

1 INTRODUCTION..................................................................................................................6

1.1 Welcome................................................................................................................... 7

1.2 History....................................................................................................................... 8

1.3 Changes in Policies.................................................................................................8

1.4 Educational Purpose...............................................................................................9

1.5 General Objectives.................................................................................................9

1.6 Expected Outcome...............................................................................................12

1.7 Appointment..........................................................................................................12

1.8 Qualifications.........................................................................................................13

1.9 Term of Service.....................................................................................................13

1.10 Status...................................................................................................................... 13

1.11 Educational Stipend..............................................................................................13

1.12 Time Away..............................................................................................................13

1.13 Absences................................................................................................................14

1.14 Unauthorized Absences.......................................................................................14

1.15 Revocation of Off-Duty Hours.............................................................................14

2 DIDACTIC PROGRAMS...................................................................................................15

2.1 Lecture Attendance..............................................................................................15

2.2 Attendance Rosters..............................................................................................15

2.3 Morning Report......................................................................................................15

2.4 Journal Club............................................................................................................16

2.5 Morning Report/Case Presentations..................................................................16

2.6 Tumor Board..........................................................................................................17

2.7 EKG Conference....................................................................................................18

2.8 OMM Lecture..........................................................................................................18

Effective 2/23/10 Version 3



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2.9 Admission Rounds.................................................................................................18

2.10 Sign-Outs................................................................................................................19

3 STANDARDS OF CONDUCT..........................................................................................20

3.1 Work Schedule.......................................................................................................20

3.2 Area of Responsibilities for Interns or Residents on Night Call....................20

3.3 Accidents to Patients............................................................................................21

3.4 Nursing Service.....................................................................................................21

3.5 Professional Care of Hospital Personnel...........................................................22

3.6 Extra-Mural Work/Moonlighting..........................................................................22

3.7 Chief Intern Job Description................................................................................22

4 COMPORTMENT...............................................................................................................24

4.1 Work Load Limitations.........................................................................................24

4.2 General Principles and Practices for Interns and OGME-1 Residents..........25

4.3 Rotation Specific Competencies.........................................................................28

4.4 Floor Responsibility..............................................................................................32

4.5 Change of Service (Non-Elective/Elective).......................................................32

4.6 General Objectives...............................................................................................34

4.7 Clinical Education Curriculum: OGME-1 Year...................................................36

5 LOGS.................................................................................................................................... 39

5.1 Important Points to Remember..........................................................................39

5.2 What to Log?..........................................................................................................40

5.3 How to Log.............................................................................................................41

5.4 Policy Statement...................................................................................................41

6 MEDICAL DOCUMENTATION........................................................................................43

6.1 Patient Workups....................................................................................................43

6.2 Emergency Patient Workups...............................................................................46




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6.3 Medical Documentation.......................................................................................46

6.4 Medical Records....................................................................................................48

6.5 Routine Progress Notes........................................................................................49

6.6 Admitting Note......................................................................................................50

6.7 Interval Notes: Off/End-of-Service Notes..........................................................50

6.8 OMT Notes..............................................................................................................50

6.9 Discharge Summary.............................................................................................50

7 ACKNOWLEDGMENT......................................................................................................52

8 APPENDICES..................................................................................................................... 53

8.1 File Checklist..........................................................................................................53

8.2 Personal Information Sheet.................................................................................53

8.3 Agreement.............................................................................................................53

8.4 Rotation Request Form........................................................................................53

8.5 Time Log................................................................................................................. 53

8.6 Patient Log.............................................................................................................53

8.7 Intern Evaluation Form........................................................................................53

8.8 Rotation Evaluation Form....................................................................................53

8.9 Time Away Request Form....................................................................................53

8.10 360° Evaluations Forms.......................................................................................53

8.11 IM Intern End-of-Year Checklist..........................................................................53

8.12 Traditional Internship End-of-Year Checklist....................................................53

8.13 FP Intern End-of-Year Checklist..........................................................................53

8.14 Pediatric Intern End-of-Year Checklist...............................................................53

8.15 Employee Expense Form.....................................................................................53




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1 INTRODUCTION

This document has been developed by the Department of Medical Education in order to familiarize interns and OGME-1 residents (herein referred to as “Interns”) with Bluefield Regional Medical Center and provides information about working conditions, key policies, procedures, and benefits affecting training at Bluefield Regional Medical Center.

Bluefield Regional Medical Center (BRMC) sponsors undergraduate and graduate medical education programs. Intern and residency training programs are conducted at BRMC. Our programs are osteopathic and accredited by the American Osteopathic Association.

As a member of the Intern or Resident Staff you are entitled to well-defined rights and privileges while you participate in the educational goals of the specialty you have selected. They are listed in your Contract and in the Graduate Medical Education Intern, House Staff, Specialty and Curriculum Manuals.

This Manual is a guidebook to the organization, goals, and specific requirements of the OGME -1 year for Interns and first year residents.

Interns have an obligation to the patient care program of the institution and to the effectiveness of the educational program to which they have been appointed. The primary purpose of the program is to advance the medical competency, knowledge and skills of the trainee with a goal of excellence in the graduates of the program.

The most important criterion for the performance of duty and evaluation of the Intern is the performance of their patient care and educational functions in a professional manner.

Professionalism includes placing the needs of the patient central to all actions, knowledge of and the ability to apply up-to-date and scientifically valid knowledge and skills for the benefit of the patient, honesty in action, word and deed, integrity and adherence to ethical standards and practices, individual responsibility, timely response to obligations, adherence to policy and procedures of the program, respect for self and others, and compassion in your care of patients and interactions with colleagues and peers.




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The proper discharge of the responsibilities of the Intern, as a professional, requires their full time effort and attention while on duty. All Interns shall remain within the Hospital as required by their duty hours and patient care responsibilities and shall be immediately available if on call. The Director of Medical Education (DME) and Program Directors have the responsibility and authority at all times to assure the Interns effectiveness in the programs.

As part of the Bluefield Regional Medical Center, the graduate medical education program is a component of a long established community hospital and shares it mission to integrate its educational program with the mission of the hospital to provide access to the highest quality medical care for the sick and injured, to advance knowledge regarding the cause, prevention and treatment of disease and disability, and to educate men and women in the healing professions.

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1.1 Welcome

Welcome to Bluefield Regional Medical Center! We are happy to have you as a new member of our family!

The mission of Bluefield Regional Medical Center is:

Our Mission:

Bluefield Regional Medical Center exists to provide our community with caring, quality healthcare at home.

Our Vision:

BRMC is a financially viable, efficient and effective healthcare provider earning the trust and confidence of our community.

BRMC is the first choice for healthcare services, providing an appropriate range of services, quality physicians and technology to meet the majority of the healthcare needs at home.

BRMC meets the expectation for healthcare excellence in our community, eliminating the need to leave home except for highly specialized care.

BRMC is the provider of choice for physicians and the employer of choice for healthcare workers.




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BRMC is an important contributor to the quality of life in our community.

The goal of the Rotating Osteopathic Internship Program is to provide a high quality program that allows each trainee a foundation for future medical training while fulfilling the American Osteopathic Association (AOA) requirements for the traditional internship year. In conjunction with the Edward Via Virginia College of Osteopathic Medicine and OMNEE, Bluefield Regional Medical Center has developed a rotating internship curriculum that meets the goals and objectives of the osteopathic internship and provides a comprehensive base for future medical training.

1.2 History

Bluefield Regional Medical Center is the administrative section for all the components of the system that includes the hospital, outpatient surgery centers, and hospital sponsored practices. The Department of Medical Education is a hospital subdivision responsible for all medical education sponsored by this institution and for the appropriate training and experience of interns and residents who are assigned here through an affiliation agreement with another institution. The Director of Medical Education is a physician who is also appointed by the hospital and the sponsoring academic institution to be responsible for the education of medical interns, residents, and students from that College.

The OGME programs are accredited by the American Osteopathic Association. Policies and procedures for OGME are largely determined by the AOA and are applied to all intern and residency programs. As a member of the intern and resident staff, you are enrolled either as a Tradition or Rotating Intern or as a Resident in an Osteopathic Graduate Medical Education (OGME) Residency Training Program, according to the residency you have selected. The hierarchy of medical education starts with the Chief Intern, the Attending Physician, the Program Director and the Director of Medical Education. Each Residency Program is also connected to the clinical department at sponsoring medical college and the Osteopathic Post Graduate Training Institute.

In this manual, the term Intern, Resident, OGME-1 or PGY-1 are interchangeable and are meant to be inclusive of each other unless specifically applied to only one of the groups.




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Your participation in the governance of Academic Affairs is critical to our success. There are two routes of access to hospital and medical staff information for intern and resident physicians: (1) The Medical Staff Committees; and, (2) regular meetings held by your Department and the DME. These are described in the next section.

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1.3 Changes in Policies

This manual supersedes all previous internship manuals and memos. While every effort is made to keep the contents of this document current, Bluefield Regional Medical Center reserves the right to modify, suspend, or terminate any of the policies, procedures, and/or benefits described in the manual with or without prior notice to interns.

1.4 Educational Purpose

The Internship is structured to provide interns with the fundamental knowledge and essential principles requisite from the application of pre-doctoral knowledge to clinical decision-making and skills. The techniques of patient interviews, clinical physical examination, the necessary skills for performing clinical procedures, and the capability to communicate clearly with patients, their families and other members of the health care team are stressed in this internship. Exposure to core disciplines will be provided in internal medicine, family practice, general surgery, obstetrics/gynecology (female reproductive medicine), pediatrics and emergency medicine.

1.5 General Objectives

During internship, under the direct supervision of an attending physician, you should attain a level of competence that will qualify you to continue your osteopathic postdoctoral training as a Resident in the discipline of your choice. Satisfactory levels of accomplishment must be demonstrated in the cognitive, psychomotor, and affective aspects of patient evaluation and management. Upon satisfactory completion of internship, you should be able to:




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1. Obtain patient information accurately, comprehensively, and systematically; obtain a thorough and accurate personal and family history; perform an accurate and complete history and physical examination; maintain appropriate demeanour and sensitivity to the patient when performing a physical examination.

2. Present a patient case in a clear clinical format, verbally and in writing, of the history, physical examination, chief complaint, an appropriate differential diagnosis, indicated diagnostic evaluations, a treatment plan with rationale for therapy based on psychosocial conditions, the pathophysiology, alterations in normal neuropsychiatric function, altered normal structure or function, or endocrinology abnormalities and anticipated results sequel; present succinctly and confidently by accurately record information shortly organizing and recording data in a concise, legible format.

3. Differentiate between important; less important; and/or, unimportant information to be recorded on the patient’s medical record; maintain adequate and up-to-date medical records.

4. Diagnose and treat the most commonly encountered diseases in primary care and community hospital practice; recognize, diagnose and treat the acute, life-threatening conditions encountered by the primary care physician; differentiate less common disease entities for diagnosis; recognize conditions which require referral/consultation.

5. Determine the need for and which diagnostic evaluations are required for the purpose of diagnosis and treatment of the patient’s current problem; interpret the results of investigative tests as they apply to a patient’s condition and/or disease.

6. Develop a comprehensive, therapeutic health care plan based upon identified disease(s), disorder(s), and defined patient needs; identify appropriate length of stay (LOS) for each patient problem, taking into consideration diagnosis related groups (DRGs).

7. Demonstrate logical decision making and clinical problem solving relative to case management; develop a patient problem list and demonstrate the proper use of problem oriented medical record (POMR) for recording progress notes and physician orders (information written in the physician’s orders must illustrate a logical association with




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the information written in the problem list and the progress note).

8. Determine appropriate clinical indications for and prescribe medications; be familiar with the pharmacology of all agents used, including indications, contraindications, appropriate dosage, possible interactions, and proper routes of administration.

9. Work within a medical team for the benefit of the patient utilizing consultations and the knowledge of appropriate allied health professionals (e.g. dieticians, physical therapists, occupational therapists, etc.) to assist in patient care and management (e.g. nutrition, rehabilitation, activities of daily living, etc.) and propose immediate, necessary steps in the medical management of the patient.

10. Be knowledgeable of the principle of bio-statics and possess the ability to interpret statistical data in literature as it applies to patient situations; utilize current medical literature to gain insights into the care of the patient and continuously update medical knowledge and medical practice skills.

11. Recognize the value of scientifically and evidence-based medical practices to maximize patient outcomes and promote the effective and efficient practice of medicine, literature searches, patient care and education, scholarly writing, research, etc.

12. Know and utilize the principles of preventative medicine, disease prevention and health promotion, demonstrate appropriate teaching techniques as an educator who instructs patients in preventive medicine, responsibility for personal health care and community medicine.

13. Know and utilize the principles of public health and population based medical practices.

14. Provide assessment and appropriate health care for acute problems of the patient as well as chronic disease management; follow the patient at appropriate intervals, both in the hospital and on an ambulatory basis, modifying the original patient management plan when necessary; determine the approximate time for discharging hospitalized patients and necessary post-discharge care.

15. Demonstrate the psychosocial skills and cultural competency required to develop trusting relationships with individual patients and their family members; establish and




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maintain a therapeutic and support rapport with the patient.

16. Promote positive, professional, ethical interrelationships with physicians and members of the health professionals in the community.

17. Understand the role of psychosocial factors, family dynamics and interpersonal relationships on the health and illness of a patient; provide that support of family therapy when required.

18. Incorporate the family unit into the health care of the patient by recognizing and allaying the fears and anxieties of the patient and family members, and attempt to understand the impact of the patient’s background and environment on his/her wellness.

19. Develop care plans and provide chronic care rehabilitative programs, hospice and palliative care as indicated for the chronically ill, permanently disabled, physically challenged, geriatric patient or terminally ill patient.

20. Demonstrate osteopathic philosophy integrating anatomical, physiological, and psychological considerations; identify and demonstrate appropriate use of osteopathic manipulative medicine (OMM).

21. Maintain confidentiality and the uniqueness of the patient as a person.

22. Demonstrate professionalism and high ethical standards in all professional, educational, personal and patient care interactions, placing the needs of the patient central. Identify, analyze, and respond effectively to ethical problems/issues that arise frequently in the practice of medicine.

23. Participate in community outreach or preventive medicine, health screening programs.

24. Exhibit high ethical standards for medical practice. 25. Demonstrate knowledge of the legal, ethical,

regulatory and governmental standards, rules, regulations and laws that affect the practice of medicine and medical professionals.

26. Assess one’s own medical competence. 27. Understand basic practice management principles

and procedures such as billing, scheduling, record keeping, etc.

28. Understand the impact of evolving managed health care environment on the practice of medicine.




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29. Develop an understanding of the osteopathic core competencies and how they apply to patient care.

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1.6 Expected Outcome

To produce clinicians who are competent, knowledgeable, and skilled, consistent with osteopathic principles and practices as well as grounded in evidence-based medicine.

To produce clinicians who are culturally competent, compassionate and embody what it means to be an osteopathic physician.

To take a holistic view and adopt a patient center approach to communication with and care of the patient.

To produce clinicians who are proficient in the AOA Core Competencies.

To have a program that is compliant with all AOA basic standards and supports a culture of excellence in learning, patient care and service.

To create an environment that fosters the advancement of medical knowledge, life-long learning and scholarly pursuits.

To train interns and prepare individuals for their career goals in specialty training, hospital based medicine, community based medicine or fellowship training.

1.7 Appointment

Policy, Procedures and Process are outlines in: Graduate Education Intern and Resident Policy and Procedures Manual

1.8 Qualifications


(Reference AOA-Postdoctoral Internship & Residency Standards and Procedures)




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1.9 Term of Service


1.10Status

You are a representative and employee of the hospital. As an intern employee, you are responsible to the Board of Directors through the Director of Medical Education. The hospital is liable for your acts. Remember – during internship you do not have a license to practice medicine outside of the institution unless on a rotation approved by the Department of Medical Education. You will not be covered by malpractice insurance unless you are on an approved rotation. Under no circumstances may the intern engage in moonlighting, i.e. employment outside of the hospital. Moonlighting is grounds for immediate termination.

1.11Educational Stipend


1.12Time Away


REMINDER: If you request time off on a day when you are scheduled for call – you are NOT excused from call. You must find someone to take your call and make that day up at another time. TIME AWAY DOES NOT EXCUSE YOU FROM CALL.




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1.13Absences


1.14Unauthorized Absences


1.15Revocation of Off-Duty Hours

In the case of delinquent medical records, or other incomplete work, the intern may be assigned extra call by the Program Director, Director of Medical Education or the Osteopathic Graduate Medical Education Committee Chairman, pending the completion of work. In the event of repeated violations of this requirement, the Intern may face disciplinary action including administrative leave, suspension without pay or dismissal from the program.

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2 DIDACTIC PROGRAMS

2.1 Lecture Attendance

Attendance at morning report, morning and noon lectures, Tumor Conferences, M & M Conferences, Grand Rounds and the didactic lectures, hands on laboratories and demonstrations occurring on scheduled educational days are mandatory, i.e. you are expected to present 100% of the time. The minimum attendance to avoid adverse action, meet the requirement of the program for advancement to the next training year or graduation and to remain in good standing is 80%. Interns who do not meet standards will face disciplinary action, from assignment to additional holiday, night or weekend call, to administrative leave, suspension, dismissal. Failure to comply may result in incomplete credit for the internship year and failure to receive an internship certificate until such time that call is completed.

2.2 Attendance Rosters

Attendance rosters will be prepared for each meeting, conference, and lecture, etc., which the interns are required to attend. These are specifically designed for the graduate education program. In order to document your training for the American Osteopathic Association, it is mandatory that these rosters be completed and personally signed by those interns who are in attendance at the time of the event. Falsification of the document, i.e. signing when not in attendance in advance or after the event, signing for another intern or resident, etc. is consider academic and professional fraud and will result in disciplinary action.

The intern assign to morning report will be responsible for writing a 3-4 line summary of the lecture on the sign-in sheet.

2.3 Morning Report

Resident, interns and students are to assemble in the designated meeting room for morning report at 7:00 a.m. daily. All house staff are expected to be present. The interns coming off of night




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call will write the name of admissions (patient initials) on the dry erase board at the front of the classroom, and review pertinent symptoms with the interns and residents coming on duty.

Scheduled educational session occurs at 7:30 a.m. daily. This will include case presentations as well as educational lectures or presentations by interns, residents, students and staff physicians on practical medical and surgical problems. After this, the interns and students should all go to their respective floors and make rounds on their patients, spending time as needed to evaluate changes or see new patients. Progress notes should be written on all of the assigned patients in preparation for teaching rounds with the trainers.

2.4 Journal Club

Journal Club is held at least monthly by the department of medical education monthly with the schedule posted. Attendance is required for all residents, interns and those students on internal medicine and ICU rotations.

Journal Club is an integral element in any medical education center. It directs education to resident, interns and medical students, as well as attending physicians and reviews current literature on specific medical problems. Journal Club is also held in other clinical departments, and attendance is mandatory when the intern is on service.

Residents and Interns review articles in the journals recently released the month preceding the review. These journals include the JAMA, Annals of Internal Medicine, American Journal of Internal Medicine and the New England Journal of Medicine. In addition, subspecialty journals may be reviewed by interns and formally presented to the Director and invited subspecialty physicians. This review is opened to all house staff. In this format, review articles are evaluated as well as original articles critiqued for their significance in the delivery of health care, and research, and the quality of the research behind the conclusions. The article should be critiqued on its content, as well as how information was gathered and techniques involved. The case presented should be first discussed with the attending physician and, if possible, have the attending physician or active physician in the case be present at the Journal Club.




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Attendance sheets are to be signed and completed with date, time, topic, and presenter’s name and then sent to the Department of Medical Education for tracking.

2.5 Morning Report/Case Presentations

Each intern will be required to present no less than four case presentations during the OGME-1 year.

The presenting intern should choose a topic at least fourteen (14) days prior to the scheduled presentation.

The topic should pertain to a recent case. The topic should reflect that intern’s clinical exposure. The topic should be very narrow and precise. Upon choosing a topic, prior to proceeding with

preparation, it should be reviewed and accepted by the Director of Medical Education.

Each accepted topic will then be given to the Medical Education Office for announcement purposes at least five (5) days prior to the scheduled presentation.

The presenting intern should have pertinent materials available on the day of the lecture (projectors, x-rays, scans, etc.).

A written bibliography is to be distributed at the lecture. It is encouraged, but not required, to have handouts

including graphs, outlines and diagrams. Each prepared topic should have been reviewed in the

recent literature as available from a search of the literature using PubMed or Medline.

The case will present the clinical findings, diagnostic evaluation, treat as well as the pathophysiological rational for the condition and the treatment of the patient.

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2.6 Tumor Board

Tumor Board will occur each month with interns, residents and faculty presenting and reviewing complex oncology cases. The interns will present the clinical case and faculty from BRMC and staff physicians will lead a multi-disciplinary discussion including review of literature, therapeutic options for treatment including medical, radiation and surgical oncology options.




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The house staff officers are notified of the case they will be presenting approximately 1-week prior to the lecture. Interns or residents will review the patient’s medical record and prepare a brief summary (10 minutes) on the high points of the case and any pertinent lab results. This information should be reviewed with the Director of Medical Education to allow an opportunity for feedback to the intern. The intern will take to the lecture the patient’s medical record, x-rays, and pathology reports for review during the presentation.

2.7 EKG Conference

Each month, selected faculty will conduct a review of basic EKG reading skills with the house staff and medical students. Initial lectures will be basic EKG review and subsequent lectures will focus on arrhythmia recognition and treatment; Acute Coronary Syndromes, inclusive of myocardial infarction patterns, and treatment; bradycardia; Tachycardia; interesting cases; ACLS review; and pacemaker/AICD guidelines and indications. Interns will additionally be quizzed during the presentations and audience participation is quite high. Formal testing and feedback on EKG reading will also occur as part of competency based training.

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2.8 OMM Lecture

Twice monthly, the Medical Education Department, the Department of Family Medicine or the Virginia College of Osteopathic Medicine’s OMM Department provide formal lecture in Osteopathic Principle and Practices and at least monthly there is a hands-on laboratory to review basic and advanced osteopathic techniques. At a minimum annually, the resident will be required to demonstrate competency in OPP/OMM using case based scenarios and simulated patient evaluations conducted by the faculty.

2.9 Admission Rounds

Admission rounds are to advance the education, medical knowledge and competency of the house staff offices by informing them of




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current, interesting cases presenting to the Hospital on the floor, as well as problem cases. Included should be a brief case presentation, differential diagnosis, current work-up and future work-up with prognosis. Discussion should occur with these cases to have everyone learning from the case. At BRMC these generally occur in concurrence with or immediately after morning report and morning educational session or may be scheduled independently.

The attending physician should be notified in advance when their case is to be presented so they may attend and contribute in the teaching.

Attendance sheets should be signed and dated; topic and presenter should also be noted and forwarded to the Department of Medical Education.

2.10Sign-Outs

All residents and interns on in-house general internal medicine, in-house pediatrics, in-house women’s health, ICU, or surgery are to meet in the Classroom not later than 5:30 p.m. with the night float intern and resident and sign out their patients. All critical patients are to be signed out.

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3 STANDARDS OF CONDUCT

3.1 Work Schedule


3.2 Area of Responsibilities for Interns or Residents on Night Call

The intern is to make rounds of all assigned patients by consulting with the nurses on the floor or at the nursing stations shortly after coming on duty. He/she should concentrate time or personal evaluations on the critical or acutely ill patients

The intern is to make rounds again soon after the change of shifts (11:00 p.m.) to determine any newly identified problems. On these rounds, the intern should again re-evaluate those critically ill patients who might have problems during the night, to be familiar with their status.

When called by nursing, the intern is to respond in person in a timely manner. Patients are to be examined and progress notes written.

The night intern should make rounds again in the early morning immediately prior to morning report to expedite the transition of care to the day medical team as much as possible.

At 7:00 a.m. the night intern is to meet with the rest of the interns at morning report to include sign-off rounds on all critical and difficult cases, and all whose condition has deteriorated.

The night intern will be responsible for patient workups on emergency admission when on service. The intern will need to complete these in the morning before going off duty.

All verbal orders must be signed before going off duty in the morning.




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All admissions are to be reviewed with the senior resident/house officer and the attending.

3.3 Accidents to Patients

The intern on service will be notified by the nursing staff of all accidents and incidents to patients.

The intern is to examine the patient immediately and report the follow up diagnostic and therapeutic services as needed to the attending.

The intern must record the findings on the Occurrence Report Management (ORM) system. The ORM application is a tool you can use to collect data, speed up the follow-up process, and help drive patient and medication safety improvement initiatives. The enterprise-wide, web-based system provides a shared platform for healthcare facilities to automate: Patient, visitor, and staff incident data collection; incident/occurrence review and follow-up plans; and analysis, reporting, and benchmarking of incident data.

To access the ORM, choose the icon-BRMC Incident Reporting, and that will bring up the opening section of the incident reporting system. By answering each question related to the incident that is being reported by using the drop down arrows when appropriate and typing in any other pertinent information, the incident can be completed and will automatically be forwarded to the department director responsible for the area where the incident occurred.

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3.4 Nursing Service

You are expected to provide assistance, demonstrate professional behavior and courtesy in interactions with all allied health professionals and nursing personnel. Should any problems arise with the nursing service or other allied health personnel do not take it upon yourself to correct the situation, but discuss it with the Director of Medical Education or if emergent, with the nursing supervisor or director on duty.




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Interns will address all employees by their surnames, prefaced by Miss, Mrs. or Mr., as that case may be, or their title, e.g. Nurse.

3.5 Professional Care of Hospital Personnel

Members of the intern staff shall not render any professional service to hospital personnel or dependents, except under the provisions of the employee health service plan of the hospital or with the supervision of an attending staff physician.

3.6 Extra-Mural Work/Moonlighting

Interns and OGME-1 residents are expected to devote themselves entirely to their training program. During this period of service, they cannot participate in any outside activities of a professional nature except educational, and only with the permission of the Director of Medical Education. There is absolutely no moonlighting permitted during internship or OGME-1 year as the intern/resident is not covered by hospital malpractice insurance and your temporary training license only covers you in the hospital at an approved rotation through the Department of Medical Education. This means that interns and OGME-1 residents are not permitted to participate in private, professional, or clinical practice wherein compensation is collected for the intern’s services. Moonlighting will be considered just cause for termination of the contract.

Remember – an Intern or OGME-1 trainee is not a licensed physician.

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3.7 Chief Intern Job Description

A Chief Intern for the Internship Program may be designated upon nominated by their peers however finale appointment is made by the DME and is subject to qualification and needs. The




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position contains both a leadership and administrative component meant to improve and facilitate the training program for residents, interns and medical students at Bluefield Regional Medical Center.

Qualifications:1. The intern must remain in good standing at Bluefield Regional

Medical Center during the course of their training.2. Demonstrates an interest and participation in the educational

programs at Bluefield Regional Medical Center.3. Demonstration of excellent rapport with peers.4. Demonstrates and participates in scholarly activity, as well as

possessing the work habits appropriate and consistent with the mentoring responsibilities of the position.

5. Willingness and ability to attend training and skill development courses or CME as suggested by the DME/ADME to prepare and guide the applicant in performing their duties as Chief Intern.

Responsibilities: (Inclusive of but not limited to)1. Act as liaison between the Department of Medical Education

and all House Staff, Medical Students and Allied Health Students.

2. Act as liaison between House Staff Physicians and Nursing Staff.

3. Attend all Osteopathic Graduate Medical Education Committee meetings.

4. Must remain current in all evaluation, logs and inpatient and outpatient charts requirements.

5. Actively mentor the House Staff, Medical Students and Allied Health Students in the areas of scholarly activity, professional/ethical behavior and work habits. The Chief Intern(s) is/are directly responsible to the Director of Medical Education (DME). In the absence of the DME, the Chief Intern is responsible to the Program Director, Administrative DME, and the Chairperson of the Osteopathic Graduate Medical Education Committee in this order.

6. Introduce Guest Lecturers/Presenters at Morning and Noon lectures.

7. Assist with development and procurement of resources to support Medical Education Activities at Bluefield Regional Medical Center.




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4 COMPORTMENT

4.1 Work Load Limitations

Work load limitations and volume caps on services:

Interns/OGME-1 residents are not to have more than eight (8) admits during any shift and not to have more than twelve (12) patients on the teaching panel that they are responsible for.

OGME-2/3 residents are responsible to supervise the clinical actions, patient management and admissions of all OGME-1 residents. The upper division resident on the service will assign all new admissions to members of the team as they occur in an equitable manner up to the limits of their responsibilities. If the junior residents “cap out” in either daily admits or total patients on their panel, the supervising upper level resident is not required to handle more than 8 additional admits per shift or less if the daily admit or teaching service cap is reached.

Teaching service will be capped at 16 admits per shift and 30 patients on the teaching service for each team when there is any combination of three junior or senior residents on the team.

The teaching service is capped at 24 patients if there is any combination of two junior or senior residents on the team and capped.

The teaching service obligations will be capped at 12 patients if there is only one junior resident or 18 patients if there is only one senior resident on the team.

Any admits or patient loads above these levels will be the responsibility of the attending physician or hospitalist supervising the service.




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4.2 General Principles and Practices for Interns and OGME-1 Residents

The philosophy is through a combination of clinical education and experience, didactic presentation and independent study provide a quality education for the student physician.

Goals and requirements of the program include but are not inclusive of the following:

Provide a training program which leads to excellence in the practice of medicine, a dedication to life-long learning and competency, and a keen sense of individual and patient responsibility on the part of the resident.

Develop an intern that perceives this goal and is tenacious in the pursuit of it.

The intern is expected to demonstrate the highest possible level of professionalism and ethics at all time and in all settings.

The intern is expected to present themselves in a professional manner, including dress, demeanour, communication and actions.

The intern will embrace the responsibility he/she has in the care of the patient and the patient’s outcomes.

The intern must develop and embrace a schedule that places an emphasis on individual responsibility for learning and patient care.

The intern will be responsible for the routine daily care and outcome of his/her patients under the direction and supervision of the attending physician or faculty.

The intern will discuss with and obtain consent of with the attending physician any proposed changes in care before initiating them.

The intern will initiate any necessary emergency patient care and notify the attending of it.

The intern will see all patients that they are responsible for as soon as possible after admission (guidelines are; 1 hour for ICU patients and 2 hours for floor patients) for an evaluation and admission orders.

Interns will see all admissions from the emergency room in the Emergency department before they are taken to the floor for admission.




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When time is available, the resident will do a complete patient workup on each patient assigned at the time of initial evaluation.

The intern will contact the senior resident and/or attending physician to review orders on all new patients before they are initiated by nursing staff.

The intern will write an admitting progress note and ensure that the H & P is performed on the day of admission (not greater than 24 hours after arrival to the floor).

The intern will round all patients assigned at a minimum once a day in the morning to evaluate status, update treatment protocol and write daily progress notes (guideline: this should occur before teaching rounds daily).

All drug reactions that occur in the patient must be recorded on the progress note immediately and reported to risk management of the hospital.

The intern must evaluate all patients on his/her service daily within the first 1 to 4 hours of each duty shift.

The intern will review/evaluate all x-rays and diagnostic evaluations pertinent to his/her patient with a faculty member or physician from the Department of Radiology.

The resident will scrub on all surgical procedures and participate in all diagnostic or treatment procedures that are performed on his/her assigned patients when every possible to maintain continuity of care.

The intern will complete any assigned discharge summaries on his/her patients designated by the attending physician within 48 hours of dismissal from the hospital.

The intern should update the evaluation and status of his/her patients on his/her service before going off duty.

Progress notes must be up to date, clear and sufficient in scope to assist the any resident, attending physician or others providing care for their patient daily.

Every intern must report the status of his/her patients and sign out each in-patient on his/her service with the night resident at prior to leaving the hospital daily.

The intern should use a problem-oriented system of progress notes or SOAP to assist in evaluation of the patient and the patient’s problems, in communication to others and in teaching others for feedback and learning.

The intern should review the case, findings, diagnostic and treatment recommendations personally with any consultant involved with his/her patients care after the consultation is completed.




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The intern is responsible to develop and deepen his/her knowledge of the diagnosis, evaluation, treatment and pathophysiology of the medical or socio-economic conditions of his/her patients through directed reading and self-study and to utilize outcome based, scientifically valid approaches to their evaluation and treatment. The resident should be prepared to present the scholarly support for their decision and actions at all times to their attending physician or faculty.

The intern must be aware of and take into consideration not only the different systems of medical practice they encounter in the care of their patients, but they must factor the economic impact of their diagnostic and treatment decisions and be efficient and well as effective in their care of the patient.

No evaluation or treatment should be ordered by the intern unless that can justify its utilization and demonstrate how it will affect the outcome of the patient.

The intern is expected to be punctual and on time to all assigned educational programs, services and assignments unless detained by essential patient care. These include departmental meetings if when assigned to that department, all daily or weekly educational sessions as scheduled, including journal clubs, Ground Rounds, M & M conferences, Tumor Boards, etc., any assigned committee meetings and autopsies on the residents former patients.

The intern will be time and available to make rounds with all attending physicians and assist in patient care at the time established by the attending physician or faculty member unless it conflicts with protected educational times established by the Program Director or DME.

Resident duty hours are generally from 0700 to 1900 daily. If not involved in educational events or rounding with attending physicians, the resident will be available during these hours to carry out his/her clinical and administrative duties, have time for individual study and development of knowledge and skills and for patient care.

Interns are not to leave the hospital during duty hours without the permission of their attending physician and either program director or DME.

The intern must be proficient in doing performing basic medical procedures, including venipuncture, blood gases, catheter placement, placement of venous access lines, N.G. tubes etc. This proficiency is best achieved and




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maintained by performing them on a regular basis maintain this proficiency, the resident must perform these functions on their patients and other hospitalized patients on a regular basis, weekly if not daily.

Residents are expected to notify their peers and colleagues of unusual or interesting medical or surgical cases in the hospital so that learning is expanded to the entire class and other residents can review cases of interest as they arise.

Each intern must fill out an evaluation of the service and faculty at the end of each rotation and this evaluation must be turned in to the Medical Education Department within 72 hours of completing the rotation. Failure to do so may result in suspension from service, assignment of additional call or duties and if more than 30 days late, suspension without pay, appearance before the Medical Education committee and disciplinary action up to and including dismissal from the program.

Each intern is expected to assist his colleagues and peers with demands of patient care, medical service to ensure appropriate care is available in a timely and appropriate manner. Each resident is primarily responsible for the comprehensive management and care of all patients on his/her educational service.

Aseptic technique and universal precautions are essential for all patient encounters and absolutely necessary in certain areas of the hospital and iatrogenic cross-infection between patients is always considered. WASHING HANDS before and after every patient contact is the best single method of preventing the spread of infection.

It is a requirement that all residents (male or female) have a female in physical presence with them when examining a female patient, no matter what age.

The intern on duty is to be immediately available to answer calls, provide required patient care services at all times.

If covering for another service or resident, the duty resident is to be immediately available to answer call and provide patient care service to all services that they are covering in a timely manner.

Patient care and procedure Logs and evaluations are to be maintained by the resident for all services, inpatient or outpatient, and turned in to the medical education office within 7 days of completion of a service.




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The resident may be called to evaluate or care for a family member/relative/friend of a deceased patient who is in distress after the demise of a hospital patient. They are not a patient of the hospital, therefore, after urgent stabilization; the residents should refer that individual to the Emergency Room for definitive care if care is required.

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4.3 Rotation Specific Competencies

Competency 1: Osteopathic ConceptsInterns should demonstrate an ability to evaluate the patient, understand expected findings associated with the patient with both normal and abnormal findings and conditions, perform a structural exam and incorporate that information into the treatment plan for the patient

The intern should integrate the findings of the Osteopathic examination with the diagnosis and treatment plan.

The intern should demonstrate holistic, patient-centered care as it pertains to the diagnosis, treatment and prevention of disease.

Intern will demonstrate an understanding of the somatic-visceral relationship, the concepts of structure and function and the role of the musculoskeletal system in disease.

Competency 2: Medical KnowledgeInterns should demonstrate knowledge surrounding established and evolving biomedical, clinical, epidemiological, and sociological and systems of medical care sciences and the application of this knowledge to the care of the individual patient as well as population based medical care.

The intern should demonstrate a solid foundation of medical knowledge as it pertains to the evaluation and care of all patients encountered by members of their discipline or specialty.

The intern should develop scientifically valid, evidenced based medical care decisions supported by current and up-to-date evidence regarding the evaluation and treatment of patients.

The intern should apply analytical thought processes to clinical situations.




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The intern should develop the knowledge and skills required to facilitate the education of patients, the public, health profession students, nurses, and allied health care professionals.

Competency 3: ProfessionalismInterns must demonstrate both high standards of and a commitment to professionalism and ethical conduct and actions, including adherence to professional standards, completion of all professional responsibilities, adherence to ethical principles, and the knowledge of and sensitivity to the special needs of diverse patient populations.

The intern should demonstrate compassion and respect for other individuals and groups, including patients, colleagues and ancillary staff members.

The intern should demonstrate sensitivity and responsiveness to individual requirements dictated by differences in colleagues or patients’ culture, ethnicity, age, religion, gender, and disabilities, et al.

The intern should demonstrate professionalism in the performance of their duties, including but not limited to productive work habits personal integrity, ,confidentiality of medical information, compassion, sincerity, responsibility, punctuality, effective time management, initiative and organizational skills.

The intern should take ownership and responsibility for patient care.

Competency 4: Interpersonal & Communication SkillsInterns must demonstrate interpersonal and communication skills that foster and advance the care and education of the patient result in effective information exchanged with patients, the public and colleagues.

The intern will demonstrate the ability to communicate effectively with the public, patients, their families, other health professionals and colleagues to create and sustain a therapeutic relationship.

The intern will demonstrate the ability to maintain accurate, timely, complete and legible medical records.

The intern must learn the application and utilization of differing systems of medical care, including the concepts of




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public health, patient centered care, electronic medical records, the applications of registries and quality systems, etc.

The intern must demonstrate the ability to work effectively with others as a member of the health care team.

The intern must communicate patient information in a clear, concise and culturally appropriate way

Competency 5: Patient CareInterns must be able to provide patient care that is compassionate, medically and scientifically appropriate and effective for treatment of health problems and the promotion of health maintaining the incorporation of osteopathic principles and philosophy.

The intern must demonstrate the ability to gather essential and accurate historical and sociological information about patients through history taking, interview of other stakeholders involved with the patient, observation, physical examination and diagnostic evaluation. .

The intern will demonstrate the ability to formulate appropriate diagnostic and therapeutic plans based on patient information, up-to-date scientific evidence and clinical judgment.

The intern will demonstrate the ability to implement patient management plans effectively.

The intern will demonstrate proficiency in the performance of diagnostic, treatment or surgical procedures that are inclusive to his/her specialty or discipline.

Competency 6: System-Based PracticeThe intern must learn the application, requirements and utilization of differing systems of providing medical care, including the principles of public health, population based medical practices, patient centered care, electronic medical records, and the applications of registries and quality systems, etc.

The intern will develop the ability to practice cost effective health care and resource allocation that does not compromise quality of care.

The intern should be an advocate for quality patient care and assists patients in dealing with system complexities.




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The intern will develop the ability to utilize clinical guidelines/care paths effectively when caring for the surgical patient.

The intern will learn to incorporate and utilize practice evaluation techniques, including patient registries, patient outcomes and practice guidelines to promote outcomes, patient’s safety and efficient practice habits.

Competency 7: Practice Based Learning ImprovementInterns must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve patient care practices.

The Interns will learn to incorporate and utilize practice evaluation techniques, including patient registries, patient outcomes and practice guidelines to promote outcomes, patient’s safety and efficient practice habits.

The intern should critically evaluate current scientific literature using principles of evidence-based medicine for enhanced care of the patient.

The intern should accept feedback appropriately and act upon areas identified for improvement.

The intern should use information technology to manage information, access on-line medical information and support his or her own education.

The intern should acquire knowledge thorough utilization of appropriate resources (e.g. texts/ literature, attending physicians or consultants, electronic sources, residents, peers, and conferences).

4.4 Floor Responsibility

An intern schedule will be distributed to all concerned; including, hospital services. This schedule will cover the assigned schedule shifts only and is subject to change at any time.

When a student is assigned to a service along with a resident, that resident is responsible for oversight of the student as well as their individual actions. .

Responsibility includes the care of all patients assigned to the service, unless the patient is specifically assigned to the care of another resident or attending not on the service panel, e.g.




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medical floor with orthopaedic or surgical patient. As the resident on that service, you are responsible for the following:

Evaluation of the patient in a timely manner after admission;

Ensuring that a complete patient workup, admission orders, admit note and H & P is completed;

Notification of the senior resident and/or attending physician of the admission of the patient, your evaluation and treatment plan;

All patients are to be evaluated by the resident at a minimum once a day at the start of the shift and their treatment plan adjusted appropriately, that the results of all diagnostic test, consultations, and treatments are evaluated and followed up appropriately;

The intern is responsible to ensure that the patients needed daily care, including treatment plans are carried out, progress notes and consultation notes are documented, etc. be carried out;

The intern will work with other health care professionals as a member of the health care team to ensure that the patient receive appropriate care and treatment;

The intern may be responsible to prepare end of service notes and/or discharge notes on all patients as assigned by the attending physician, this task cannot be regulated to a medical student.

4.5 Change of Service (Non-Elective/Elective)

In order to expedite change of services on the part of the resident, it is necessary that contact with the attending physician as well as the resident currently on the service be made in advance with the trainer.

Non-Elective: The week before the change of service, the intern is to contact the attending physician to determine when, where, and to whom to report. The intern is then to report to that service after morning report on the day of the scheduled change.

The trainer should give the intern an orientation to the service the first day of the service. This should include time, place and person of contact on the service. Rounds, duties and core reading assignment will be discussed with the intern.




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In-House Elective: Not less than one month before an elective rotation with a member of the medical staff of BRMC, the intern is to contact the Department of Medical Education to clear the choice before contacting that individual physician. A letter will be sent from the Director of Medical Education/Program Director to the attending physician to verify the dates of the elective, the resident involved and detail the duties, obligation and responsibilities of the attending physician once the rotation has been approved. Out of House Electives:Outside electives will be approved by first by the program director and then by the Director of Medical Education not less than 3 months in advance of the elective. They are scheduled at the sole discretion of the Director of Medical Education and are allowed only for intern in good standing. Those with incomplete medical records, poor compliance with administrative and documentation requirements including logs, evaluations, those with poor attendance records, etc will not be allowed to take rotations outside of BRMC and face having a previously scheduled elective cancelled for cause. Any elective outside of the System, beyond requiring DME approval and scheduling at least three months in advance, will be permitted only if the outside institution has signed an affiliation agreement prior to the start of the rotation.No more than one out of house elective will be allowed in any one year. Out of hospital elective are not accumulative from year to year.

Elective Purpose: This rotation should be used to increase depth of medical knowledge and clinical skills in an area of need or interest of the resident, to resolve deficient’s in knowledge or skills identified by the resident or trainers, or to broaden knowledge and exposure in areas that have not been adequately developed by the resident or program. The resident may rotate on a service that is a part of the core curriculum of the program provided that the service can accommodate the resident without detracting from the education of other residents or students. The resident may elect two different services for the month (a minimum of two weeks on each service is required for approval of an elective for continuity of care and quality of education) or may request a service different from those already established. In the later case, it will be the responsibility of the Director of




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Medical Education/Program Director to determine its acceptability. The service must comply with several requirements consistent with standards of education for the resident: prior affiliation agreements, a structured scholarly and clinical education program, a research experience and opportunity for individual knowledge advancement through study and assigned reading.

Also, any in-house elective service, the intern is required to attend all educational sessions including autopsies, maintain responsibility for call, clinic duties and hours, etc unless dismissed by program director or DME.

Specific details: If the service is other than an established service, an outline of the resident’s educational goals while on this service may be required.

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4.6 General Objectives

At the completion of the training program, the graduate shall:

1. Accurately identify potential medical problems using clinical skills:

a. describe the medical problems presentedb. define information in the patient record which aids in

said descriptionc. elicit and record appropriate history which defines

the problemd. perform an accurate physical examination to identify

and confirm the problems2. Utilize and interpret diagnostic studies, including but not

limited to radiographic, laboratory and ancillary testing to define or discover problems:

a. accurately diagnose problemsb. describe potential etiologies for each presenting

problemc. identify signs and symptoms for each problemd. prioritize findings with respect to potential etiologiese. rank potential disorders by likelihood based on

presence or absence of findings3. Develop a evaluation plan to Confirm the diagnosis of the

patient medical problem :a. describe the diagnostic resources for each disorder




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b. generate a diagnostic plan to appropriately confirm the disorder

c. perform diagnostic procedures consistent with the expectation of the residents specialty and discipline when appropriate

d. properly interpret results of testing, recognizing the relative sensitivity and specificity of the tests

e. understand cost effective diagnostic planning4. Competently treat the patients psycho-social or medical

problems in the individuals cultural or socioeconomic circumstances:

a. define the cultural or social needs and circumstances of the patient

b. describe the conventional and alternative therapies for each problem

c. generate treatment plans which are cost effective as well as efficient

d. monitor response to initiated treatment, including appropriate follow-up testing if needed

e. determine efficacy of chosen treatment5. Communicate effectively in both written and verbal forms:

a. use standard English effectivelyb. use accepted medical terminology appropriatelyc. develop listening skills for patient, family, and

ancillary providersd. effectively and sensitively respond to patient

questions and fears or concernse. record data and plans clearly and completely in

progress notes, summary reports, history and physical

f. develop prompt responsiveness to requests for information or explanation

g. demonstrate competency in the utilization of use of electronic health record systems, web based registries and quality systems, electronic information and research systems

h. demonstrate an understanding and ability to utilize the principle of epidemiology and bio-statics for the evaluation and treatment of the patient

6. Demonstrate professionalism:a. develop and demonstrate characteristics consistent

with professional ethics and standards expected of an osteopathic physician, including but not limited to compassion, competency, empathy, collegiality,




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personal responsibility, professional commitment, involvement, respect for and cooperation with other demographics and individuals.

b. definitive leadership capabilities when dealing with house staff, students, other health care professionals, patients, or the public

c. demonstrate honesty, reliability, and morality.d. develop a commitment to the osteopathic medical

profession, the individual greater community and society for the advancement of medical knowledge and medical care.

7. Develop appropriate professional practice evaluation tools and boundaries along with a commitment to life-long learning and professional growth and development:

a. demonstrate ability and commitment to use of knowledge and skill development tools including continuing medical education, journals, electronic knowledge, research and educational resources and computer-assisted instruction, teaching, and involvement in conference activities both as learner and instructor.

b. recognize personal limitations and obtain appropriate consultation where necessary.

c. understand requirements of different system of medical deliver, the managed care environment, the patient centered model, community based or population based medical system and how to maximize patient care and resources recognize the medico/legal aspects of care, and manage risks appropriately.

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4.7 Clinical Education Curriculum: OGME-1 Year

Clinical education at Bluefield Regional Medical Center is provided during thirteen (13) four weeks block of instruction normally beginning on July 1st and ending on June 30th for the academic year.

All Interns/Residents programs and curriculum are designed to meet the requirements of the AOA standards as well as the curriculum of each of the resident training program specialties provided at BRMC, provide the opportunity for the development




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of competency in the intern/resident, promote excellence, life-long learning and advance quality medical practice and patient care and meet the patient care needs of the institution.

TRADATIONAL ROTATING INTERNSHIP (OGME-1):Each intern will complete the following rotations during the year:

Two blocks of In-house Internal MedicineTwo block of Block NightsOne block of General SurgeryOne block of PediatricsOne block of OB-GYN/Women’s HealthOne block of Emergency MedicineOne block of ICU/CCUOne block of Family MedicineOne block of Medical Selective One block of Surgical Selective One block of Electives

FAMILY MEDICINE OGME-1 RESIDENTS:Each resident will complete the following rotations during the year:

Two blocks of In-House Internal MedicineTwo blocks of Block NightsOne block of General SurgeryOne block of PediatricsOne block of OB-GYN/Women’s HealthOne block of ICU/CCUOne block of Family MedicineOne block of Medical SelectiveOne block of Surgical SelectiveOne block of Emergency MedicineOne block of Electives

INTERNAL MEDICINE OGME-1 RESIDENTS:Four blocks of In-House MedicineTwo blocks of Block NightsOne block of ICU/CCUOne block of General SurgeryOne block of Emergency MedicineOne block of OB-GYN/Women’s HealthOne block of CardiologyOne block of PulmonologyOne block of Elective




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Medical Selective include but may not be limited to the following: gastroenterology, cardiology, pulmonary, neurology, infectious disease, endocrine, rheumatology, dermatology, and nephrology.

Surgical Selective include but may not be limited to the following: orthopedics, urological, C/T/V, neurology, gynecology, plastics, anesthesia, and radiology.

Internal Medicine and Family Medicine Residents will have a half day each week of attendance in one of the continuity care clinics of their specialty associated with the hospital as a concurrent requirement.

The course description, evaluation techniques, competencies and outcome expectations, etc. for each rotation/service are detailed in the graduate education curriculum manual supplied to each intern/resident.

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5 LOGS

Documentation of your educational and clinical experience is an essential part of any training program and important for licensure, privileges, certification, and re-imbursement throughout your medical career. It is a principal adopted by Medicare, third party carriers, as well as the legal profession that “if it is not documented – it did not happen”. To avoid frustration at the end of your graduate medical education training, and to enhance the satisfaction within a training program, it is extremely important that timely logging of clinical activities take place.

It is important to realize the essential nature of logging. The principal objective for this is:

1. To document to certifying agencies that you have accomplished a significant amount of clinical exposure and expertise to have graduated and/or be certified/credentialed;

2. To document for the Department of Medical Education, the individual program directors and trainers, that the education program is serving their individual educational goals and providing the trainee with adequate opportunity to learn. Outside accrediting inspection agencies do, in the normal course of their review process, examine trainee logs;

3. To document your experience for the purpose of applying for hospital privileges in the future -- This point is the most important and concrete for the individual trainee. It is your personal future! Do not assume that by doing rotations at any particular institution that privileges will automatically flow so that logs need not be kept. Documentation is frequently important when providing letter of reference for future training programs and/or when applying for staff privileges. Frequently, individuals relocate on several occasions, and each new institution requires documentation of prior experiences.

Logs are due at the completion of the rotation. If not turned in within seven (7) days, disciplinary action may occur.




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5.1 Important Points to Remember

Responsibility of logs lies exclusively on the shoulders of the individual trainee, and is an American Osteopathic Association requirement for graduation from the program.

Log entries should be easily verifiable. It is a normal course of the hospital internship inspection for an inspector to request records. Charts are pulled for verification that the trainee participated in the care of a patient. Therefore, the logs should include some evidence of the level of involvement in the case. The medical record as well should reflect documentation of participation by the intern or resident. Therefore, if multiple people are attending to a particular patient on a day that all parties contribute to the care, it should be noted on the medical record (i.e., attending/resident/intern/MSIV).

The responsibility for archiving the logs falls primarily on the shoulders of the trainee. The fact that the original copies are handed to the Medical Education Office, should not give the trainee a false sense of security that the documentation is safely stowed away. Record catastrophes do happen. It is; therefore, strongly emphasized that all logs and records be copied and retained in the intern’s personal possession. Photocopies are your personal insurance policy. In accordance with AOA policy, BRMC is required to retain your logs for only five years.

5.2 What to Log?

Any pertinent encounter, whether it is a hospital visit, office visit, or house call, should be recorded. Include the patient’s name, identification number, or other indicator as well as the diagnosis or multiple diagnoses and level of involvement.

Issue of diagnosis is often time critical because only the principle diagnosis is often recorded. However, patients frequently present with multiple health issues. To attest to a diversity of experience, it is important to include any supporting secondary diagnoses.

Procedures are particularly important. Institutions when credentialing frequently request documentation of experiences. For this purpose, procedures are critical activities to be logged.




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Any outside educational experience including: Academy meetings, educational seminars, and programs that are not held in-house or recorded in any other manner. We do maintain records internally of lectures, presentations and meetings. All activities out of the institutional walls would be lost unless included in your logs. On-call experiences are often looked upon as secondary activities, but are still a part of your net clinical experience. Therefore, they should be recorded as well.

It is mandatory that reading, lectures, case presentations, or journal clubs, etc. attended and/or presented be documented in your log.

5.3 How to Log

Be as specific as possible. Include name or initials, date, place, preceptor, and level of involvement. This last item is most important for procedures that you may want privileges for (i.e., observed 15 c-sections, participated or assisted in 20, did 2 under observation). All entries supported by hospital medical record number, date, time, location, preceptor, level of participation. You may want to mention complications or other related specifics that you handled.

In short, logs help to aid the function of the program, but most directly benefit you. Keep them current, and complete them in an organized manner. Do not procrastinate! The Program Director may call for the logs at any time during the year for spot review. They are your responsibility.

5.4 Policy Statement

To underscore the importance of this activity and to insure timely compliance, the policy on log and evaluation completion will be on the same basis as any medical record within the hospital. The educational objective here exceeds assuring mechanical compliance with submitting logs. It is designed to encourage a physician early in his career, the ability to follow through with the medical record in a timely manner. This is a shared expectation of all institutions that you will be involved with, so that it is appropriate to establish good habits from the beginning.




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1. Patient logs and preceptor evaluations are to be in the Medical Education Department within seven (7) days of completion of a rotation. Remember: LATE LOGS = SUBJECT TO DISCIPLINARY ACTION!

2. Time log is due to the Medical Education Department immediately upon completion of the rotation.

3. For longitudinal experiences that extend over the year period, it is expected that they be completed within fifteen (15) days of the completion of an academic year.

4. If logs are not completed in this timely manner, disciplinary action up to suspension or dismissal from the education program may take place immediately upon direction of the Director of Medical Education.

5. Any time lost from the educational program will then be made up with compensatory time at the end of the educational program. A reminder – administrative leave and suspension also means that time off is not compensated time. So, adjustments will be made on the next pay check.

Exception to the rule:1. Catastrophic illness where the intern is not physically

able to complete his/her logs.2. Catastrophic illness prohibits his/her preceptor from

filling out the evaluation form. Consideration will be given to late reports only if an explanation is provided by the preceptor, in writing, and accompanies the log and evaluation.

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6 MEDICAL DOCUMENTATION

6.1 Patient Workups

Service and trainer: Patient workup assignments, whenever possible, are the responsibility of the intern or resident on the service at that time.

Priority of patient workup: Emergency admissions, surgical admissions and medical admissions.

Weekends: The education team, Residents, Interns and students on weekend duty will pick up all admissions of that weekend. Residents and Interns will write ICU notes.

Nights: The night intern is expected to do patient workups on emergency patients admitted through that department while on duty.

Patient admit notes are to be written as soon as possible as previously outlined and complete workups including H & P are to be completed and recorded within 24 hours of admission: H & P’s must completed before a patient is taken to surgery in all cases, and the night before surgery in elective cases.

Progress notes are written when the patient workup is completed, so stating, (e.g., “patient H&P dictated”) plus working and differential diagnosis.

Medical Student physical workups are the responsibility of the intern or resident on the service and are to be reviewed and countersigned by the resident in addition to the attending physician. When no intern/resident is assigned to the service, then the attending physician is primarily responsible.

Forms for documentation of admit note and H & P are available in the Medical Records Department for patient workups. Forms should be on the patient’s chart at the time of the workup. The advantage of the form is the availability of the patient workup on the chart. The disadvantage is that all patients are different and no one form fits all patients. So, when using a form, remember – add all pertinent information even though the form does not ask it. Make it complete, and make it fit the patient.




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A complete patient workup should include the following:

1. Pelvic examination, including cervix with permission:a. Married females any ageb. Single females 21 years of age and older c. Single females under 21 years of age with complaints

referable to pelvis (a recto-vaginal bimanual may be substituted).

Any recto or vaginal examination performed on a female patient less than 18 years of age at the direction of the attending physician and with the written permission and informed consent of the patient, her guardian and family.

Exceptions:i. Patient Refusal: If a patient refuses the examination,

the intern is to contact the attending physician, informs the attending physician of the refusal, and suggest that the attending contact the patient to discuss the importance of performing a vaginal/rectal examination while in the hospital.

ii. Patients that are in a comatose or moribund state do not require such exams unless there is evidence of vaginal bleeding or significant pathology directly related to the G-U system.

iii. Patients with NO signs or symptoms related to the abdomen or pelvis, and NO previous low abdominal or pelvic surgery.

2. Rectal Examinations:a. Adult males and females over 20 years of ageb. Patients of any age who have any referable

symptoms to the system

Exceptions: i. The patient who refuses, (contact the attending

physician).ii. Patients with NO signs or symptoms related to the

abdomen or pelvis.iii. Comatose or moribund patients except where GI

haemorrhage mass is suspected.




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iv. Patients where such is contraindicated at the time, such as rectal abscess, pelvic or femoral fractures, acute MI, etc.

Whenever you do not do the pelvic and/or rectal examination on a patient whose age and conditions suggest it should have been done, BE SURE TO: Dictate or write in the patient’s own words the reason for absolute refusal, and that the attending physician was contacted.

When you write in the progress note “patient workup dictated” add the information to that note. Then the attending physician is aware.

3. Osteopathic Structural Examination: An osteopathic structural examination is to be done on each patient examined by a medical student, intern or resident unless pathology or morbid condition prohibits.

Findings, correlations, recommendations are a component of the examination and should be recorded

4. Provisional diagnoses are to include all established diagnoses, including obesity and hypertension, etc and the osteopathic findings (ex. somatic dysfunction C-7).

5. Diagnostic evaluation and initial treatment plans are to be summarized (C.T, surgical consult, control pain, hydrate)

6. All patient workups are to be signed by the trainee to be considered complete and must be co-signed by the attending.

DICTATION AND NOTES:“Non-contributory”, “essentially negative”, “deferred”, “negative”, and “normal” may NOT be used in describing physical findings unless specific to the disease, symptoms, sign or physical finding, (e.g., “GI system normal” is not permitted but “Appetite normal” is permitted.) WNL = we never looked to clinicians, medical record specialist and attorneys.

When dictating, give patient’s name, spelling it if there is any question, sex, age, hospital number, attending physician and date. When dictating, follow the heading and format established




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by the hospital or clinic. . WRITE LEGIBLY and make all marks carefully and neatly so there is no mistaking what is meant.

When using a standardized form, complete it by indicating the status of each item with descriptions for all abnormal findings Additional facts or findings not specifically included in the form must be added when pertinent to the patient workup. This includes additional negative findings.

Put patient’s name and hospital number on the top of each page of your history and physical and each page of your progress notes, in addition to each page of physician orders.

Your name and status as well of the attending or consulting physician with who the intern/resident is rotating are to be on each note, H & P, order, etc.

6.2 Emergency Patient Workups

When time does not permit for a full patient workup because of the emergency nature of the patient, you may do an emergency patient workup on the patient t. You are obliged to complete the patient workup as soon as possible, in no case longer than 24 hours after admission to the hospital.

This consists of, at a minimum, a chief complaint, onset and course, allergies for the history and a general statement, evaluation of cardio-pulmonary and gross neurological status as well as description of the affected system findings.

6.3 Medical Documentation

Formal communication in medicine is achieved by documentation in the medical record. To help maximize the quality of medical care among providers, support patient safety and risk management, support economic administration and minimizing liability.

It is essential to document all findings that are essential to the support of a diagnosis and rationale for evaluation or treatment. These findings may be positive or negative. All portions of the record should be consistent. That is the admitting note and the history and physical should refer to similar features. Usually the




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admission note is a more concise summary of what the important features found in the history and physical. The admit note further indicated clinical course and treatment plans. One should not simply refer between documents as “Note H&P”. In the process of the physical examination, it should be clear as to what was and was not examined. In the event an area was not included, it should not be stated that it was “deferred”, but rather an explanation as to why the examination was not performed should be made clear in the record. If a standardized medical form is being filled out, all areas of that respective form should be addressed in one way or another. Continuing progress notes need not necessarily address processes that are unchanged, but should detail an ongoing problem that is evolving. It is often better to make a general statement concerning impression than to attempt list of differential causes that may be incomplete. The generalized statement will suffice for the documentation and not waste effort and time.

One will occasionally come across a difficult situation where an unusual happening or adverse reaction has taken place. Avoid any commentary as to legal implications and restrict your comments only to what is relevant to the patient care and patient’s condition at the time. Keep the statement as factual as possible, never misrepresent facts, and do not attempt to colour them either positively or negatively. Use purely professional style in making your record entries. All documentation should be professional; never should you record unprofessional comments nor attempt to be joking, overly melodramatic, blaming, or judgmental.

The medical record is not a location to “joust”, or carry on a medical debate between other health care practitioners. At all costs avoid any reference to blame, culpability, ability, or carelessness.

The professionalism, sincerity and credibility of your records is critical. First of all, they must always be legible. A record that is unreadable does not exist. If there is ever the occasion to change a medical record, it must be done carefully and in one of two potential ways:

1. It is to place a single line through the deleted material and initial, as well as dating the change. Never, ever destroy,




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re-write, cross out, obliterate, or make unrecognizable the original entry.

2. The second alternative in making a change in a medical record is to simply make a new note referring to the prior comment, document your correction and again – date, time and sign it.

If a patient has been injured or a medical complication has occurred, the appropriate mechanism of documenting that is in an incident report. This is legally undiscoverable as long as it is not referred to in the original document. In the medical chart – NEVER state that a risk management activity or an incident report has been filled out. Simply record the facts of the situation. If the incident involves any medical equipment, carefully preserve, but in no way alter or destroy it. Sequester it and make it available to the Risk Management authorities.

In dealing with the patient in terms of complication, it is always the physicians imperative to show concern for the welfare and comfort of the individual at hand. Initially, do not volunteer any admission of negligence or blame and avoid any statements that would imply that something has gone wrong until you have notified and discussed the problem with the attending physician. If an injury has occurred, never provide false statements or misleading expressions. Again, examine the patient and notify the attending physician. Although it is appropriate to avoid being overly solicitous, it is equally appropriate to show a reasonable amount of concern and empathy for the patient and family. Never ascribe blame to people, medical equipment, or situations. Doing so is often a reflex response that is given without objectivity and without the ability to consider all the influencing circumstances. As house staff personnel, it is always proper to refer a patient or concerned family member to the attending physician. They ultimately maintain the responsibility and also usually have the greatest rapport and understanding of the family/patient situation. If you feel uncomfortable in discussing the matter with the patient or family, it is best to avoid doing go. Make an appropriate referral to the attending physician or the individual in charge. Nursing supervisors and personnel often have a high level of experience in these matters and are often valuable resources. It is also very important to take preventive action. If a recognized potentially dangerous situation exists, take immediate action that would be necessary to protect the patient from potential injury, harm or any adverse effect. It is usually best to warn the attending physician. If you




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are aware of patient or family dissatisfaction of the health care efforts, bring this to the attention of the attending physician.

Medical Documentation Top of the Document

6.4 Medical Records

Always write with a blue or black pen, as some other colours of ink will not Xerox adequately for insurance and legal purposes. Write legibly!

1. Physical workups must be completed and recorded within 24 hours of admission (unless critical patient) or prior to surgery whichever comes first. Surgery workups should be written so that the medical information is readily available.

2. When a physical workup and H & P is performed, the resident should also produce a progress note. It is to be written immediately following the physical workup.

3. When responsible for an admitting progress note, it is to be written immediately following the physical workup.

4. When responsible for interval progress notes, they should be written every working day. If the condition of the patient changes during the day, extra progress notes are to be written.

5. Case summaries, when assigned, are to be done within 48 hours of discharge of the patient. Everything you write on the chart must be signed. When you write an order always include the name of the attending physician first, (e.g., James Monroe, D.O./Peter Smith, D.O.)

Remember – the admitting physician may not be the attending physician at the time.

6. Whenever writing orders, always explain the reason for your evaluation or treatment orders in a progress note.

7. All orders and progress notes must be dated, timed and signed.

8. Medical records may be checked out of the Medical Record Department only for their use in patient care or educational sessions. They may NEVER be taken out of the hospital.

9. Physical workups may be delegated to a medical student; however, the intern/resident on service will be directly responsible for the accuracy of such physical workup examinations and must countersign it.




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10. All charts must be completed and signed within fifteen (15) days after the patient is discharged. Therefore, after seven (7) days, you will be considered delinquent in charting unless you are waiting for dictation to be typed. Medical Records will make your incomplete charts available to you at any time. If you are delinquent repeatedly, disciplinary action will be taken.

CHARTING IS A HABIT – Good or bad it is up to you!

6.5 Routine Progress Notes

1) Before writing progress notes, always identify your service. Conclude your note with your signature, printed name and pager number. Most of the services require daily progress notes, and the SOAP format is usually acceptable. However, an ICU progress note is almost as detailed as a new complete H & P.

2) Do not over-use abbreviations. When using abbreviations, follow the guidelines from the hospital manual.

3) On all admissions, please use the following guidelines:a) Progress notes, dated and timed, shall be written by all

participating Physicians or members of the house staff on all phases of a patient’s hospital stay. All progress notes should be in the SOAP format.

b) The admitting note (admitting summary) shall briefly state the chief complaint, the symptoms, and the physical findings that led to the working diagnosis, the expected therapy, and the possible consultations.

c) All significant physical changes, new signs and symptoms, complications, consultations, and treatment including manipulative therapy shall be recorded.

d) Progress notes shall describe in proper continuity, the course, progress, treatment, and disposition of the case.

e) Every progress note shall be signed by the house officer writing that note. The attending physician shall countersign your note after appropriate CMS documentation or may write his or her own progress note.

f) The final progress note, which includes the discharge summary, shall be performed by the house staff officer and signed or counter-signed by the attending physician.




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6.6 Admitting Note

This note must briefly state the chief complaint, the symptoms and physical finding that lead to the working diagnosis, the expected diagnostic regimen, initial therapy and possible consultations; also, the prognosis as of that time.

6.7 Interval Notes: Off/End-of-Service Notes

These must cover current status and all significant physical changes since admission, new signs and symptoms, complications, consultations, procedures, results of diagnostic evaluations and significant treatment provided. They shall describe in proper continuity the course, progress, treatment and disposition of the case. Notes may have to be written several times a day, if the patient’s changing condition warrants it, or once a day may suffice on assigned cases.

All progress notes shall be dated, timed and signed by the physician writing them.

6.8 OMT Notes

Record all procedures, including OMT in a procedure note and refer to the procedure in the progress notes. Include the biomechanical diagnosis for which you are treating (e.g., “somatic dysfunction of _____ due to _____”). Date and time as you do for all progress notes. Record the result each time an OMM treatment is applied. If it is a series of treatments, record summative results after several treatments.

6.9 Discharge Summary

The note must include all information normally included in an end of service note in summary. This must include a review of the patient’s hospital stay, findings and treatment, his condition on discharge, and the disposition of the case. It shall describe the termination of the physician’s responsibility for the hospitalized patient, state whether the admission diagnosis and chief complaint have been resolved, discuss any complication that developed during the patient’s hospital stay, indicate whether diagnosis and treatment have been justified, or whether




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a diagnosis could not be established. Document discharge and follow up instructions, i.e. medications, diet, etc.

With regard to death, the matter of autopsy shall be discussed and all pertinent information obtained for the autopsy shall be recorded in accordance with State laws. If an autopsy is refused, the reasons for such refusal shall be stated. It is mandatory that interns write a discharge progress note on patients on their service.

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7 ACKNOWLEDGMENT

I acknowledge that I have received a copy of the Bluefield Regional Medical Center Intern Manual, and I do commit to read and follow these policies.

I am aware that if, at any time, I have questions regarding the Intern Manual, I should direct them to the Administrative Director of Medical Education or the Director of Medical Education.

I know that Bluefield Regional Medical Center policies and other related documents do not form a contract of employment and are not a guarantee by Bluefield Regional Medical Center of the conditions and benefits that are described within them. Nevertheless, the provisions of such Bluefield Regional Medical Center company policies are incorporated into the acknowledgment, and I agree that I shall abide by its provisions.

I also am aware that Bluefield Regional Medical Center, at any time, may on reasonable notice, change, add to, or delete from the provisions of the company policies.

___________________________ ___________________________Intern’s Printed Name OGY Level

___________________________ ___________________________Intern’s Signature Date

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8 APPENDICES

8.1 File Checklist8.2 Personal Information Sheet8.3 Agreement8.4 Rotation Request Form8.5 Time Log8.6 Patient Log8.7 Intern Evaluation Form8.8 Rotation Evaluation Form8.9 Time Away Request Form8.10 360° Evaluations Forms8.11 IM Intern End-of-Year Checklist8.12 Traditional Internship End-of-Year Checklist8.13 FP Intern End-of-Year Checklist8.14 Pediatric Intern End-of-Year Checklist8.15 Employee Expense Form

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