Department of Medicine
Resident Clinic
8 Mile Lahser Health Center
Operational Manual 2003
Welcome
The
8 Mile Lahser Health Center Clinic Staff welcomes you and looks forward to
working with you and making your training at the facility one that encourages
the acquisition of knowledge, skills and the dedication to our clinic
population.
Table of Contents:
1. Goals of Ambulatory
Clinic teaching.
2. List of important phone
numbers.
3. Schedule of Resident
Clinic and Attending.
4. Overview and Patient
Schedule.
5. Clinic Schedule hours and
Clinic Policies.
6. Clinic Charts.
7. Resident Chart boxes.
8. Resident Triage.
9. Hospitalization.
10. Clinic Evaluation of
Residents.
11. Medication Samples.
12. Absences.
13. Prescription Writing.
14. Nursing.
15. CMR Responsibilities.
16. Faculty
Responsibilities.
17. Preventive Medicine
Guide Lines.
18. Procedure room.
19. Special Situations.
20. Ambulatory Research.
21. Q/A Chart Reviews.
Goals of
Ambulatory Teaching Clinic
Patient centered not disease
centered focus.
Providing the continuity of
care.
Teaching residents time
management skills.
Demonstrate efficient use of
resources.
Interpretation of diagnostic
testing in ambulatory problem solving.
Teaching residents how to do a focused history and
physical examinations.
Management of chronic
diseases.
Assessment of disability.
Consultation and referral
skills.
Understanding how to be an
advocate for patients.
Monitoring and providing
comprehensive preventive care.
Understanding managed care
and the billing system.
List of important phone numbers.
Medical Director: Muhammad Y. Karim, MD: 313-966-3565
Associate Medical Director:
Clinic Chief Medical Resident: Darshana Tawde, MD: 313-592-3608
Clinic Manager: Kim Bardwell, RN: 313-592-3526
Office Front desk: 313-592-3680
ID/GI:
Yellow nursing station:313-592-4595
Red nursing station: 313-502-3521
Purple nursing station: 313-592-3524
Admission Coordinator Sinai-Grace Hospital
ED Department: 313-966-1090
Referral for other providers or tests:
Sheryl: 313-592-3566
Overview
and patient Schedule.
1. The
adult Medicine Clinic is in the
2.
Each Resident in the first, second and third year will have clinic one
afternoon per week.
3.
Residents will be assigned to a clinic day for the year and are expected to
arrive at clinic at
4.
Residents are assigned to see patients by appointment so starting on time is
important!
5.
Each Resident will assume and/or develop a panel of patients for whom he or she
is responsible.
6.
Generally, a PGY-1 will assume patients of graduating PGY-3.
7.
PGY-2 &3 will also see patient of those residents on vacation and Residents
who are post call during their ICU rotation.
8. on site supervision will be provided at all
times by attending physicians. Each case should be reviewed with the attending
physician.
9.
The patient records and the encounter form should be counter-signed by the
attending physician.
10.
A primary nurse will be assigned to work with each resident at the health center.
11.
The purpose of having an assigned nurse is to provide the resident with
consistent staff support to meet patient care needs and provide the patients
with secondary contact service.
SCHEDULING:
Patients
are seen by appointment. Continuity of care is strongly emphasized and patients
are scheduled with their assigned resident whenever possible. Patients will be
scheduled as follows:
PGY-1:
1 new and 3 follow-up only first 6 months.
PGY-1:
Next 6 months 1 new and 4 return.
PGY-2:
2 new and 6 returns.
PGY-3:
2 news and 6 returns.
Time
allotment for a new patient is usually 45 minutes for PGY-2 &3 and an hour
for PGY-1 and time allotment for established patients is 30 minutes for PGY-1,
2&3.
The
attending supervisors based on resident load, may redistribute patients to
other residents.
Clinic hours: 1
15-1:30: Lab review and didactic by supervisor assigned.
Residents
may not leave the clinic without the permission from
Supervisors.
Arriving
time is important for patient care, education and running the clinic smoothly.
If,
for any reason, unable to attend the clinic, you must page the attending
supervisor for the day and also the nurse manager so your patients will be
notified in the clinic.
All
residents must swipe the card on the computer in the conference room and thus
record your arrival time to clinic.
A
sign in sheet will be at your assigned nursing station.
Unless
you are presenting at
Charts:
All
new patients should have a complete history and physical (including the genital
exam) done.
Writing
must be legible and your beeper number must be written under your signature.
All
notes must contain assessment and plan including return to office time frame.
All
patients seen after hospital discharge should have their discharge summary
printed from the CIS and placed in the chart.
All
notes must be co-signed by an attending physician supervising in the clinic.
All
progress notes should be in SOAP format.
All
communication with the patient including the telephone calls should be
documented in the clinic chart.
The
clinic chart is a legal document subject to review by lawyers,
Insurance
companies and peer reviews.
All
non-compliant patient behavior should be documented clearly.
There
should be a notation in the chart that patient’s case was discussed with the
attending physician.
Resident
Chart boxes:
Patient
labs, diagnostic studies and disability papers will be placed in your
designated box.
Upon
arrival at the clinic you should check your box and complete all forms and
review study results.
If you are unable to reach a patient for
abnormal lab test follow up, please send a preprinted letter signed by you to
the patient asking them to make an appointment as soon as possible. The letter
should be handed to your respective nurse to also include a copy in the chart.
If
the patient still doesn’t contact you, you have to send a registered letter.
All
stat labs ordered from the clinic will be called to the clinic attending on
call to follow up based on gravity of the abnormal lab.
If
Resident on Vacation he will delegate his peers to follow up on labs in their
chart boxes.
Resident
Triages.
Based
on clinic flow, show rate and patient’s severity of illness, there are times
you may be ask to see patients not initially on your schedule.
Patients
seen urgently will be schedule follow-up appointments with their assigned
clinic residents.
New
patients who arrive one hour or more late for an appointment will have a
focused visit with SOAP note documentation and be rescheduled for a complete
history and physical.
Hospitalization:
If
a resident finds any patient in distress, please alert the supervising
attending and nursing staff immediately. If patient is unstable, call 911.
All
patients that are hemodynamically unstable should go to ER via ambulance.
Under
No circumstances you can leave your patient before help arrives unless
excused by supervising physician.
Residents
should call the ED attending in advance and discuss the case and document the
conversation in the chart. Clinic attending on call should be paged and
informed about the admission. Alert the nursing staff early that the patient is
going to the ED so the ambulance will be called in a timely fashion.
Patient
who are stable but require hospitalization should be admitted directly to the medical
service at Sinai-Grace.
After
discussing the case with the supervisor, call the clinic attending on call and
report the case. Then call Sinai-Grace hospital admitting and report that the
clinic physician on call for direct admission has accepted the patient. Ask the
clinic staff to direct the patient to hospital.
Patients
discharge from the hospital should have outpatient medical follow up within 5
to 7 days with the assigned resident.
Clinic
evaluation of Residents:
Residents
in the clinic will be evaluated in the clinic by their supervising faculty
twice a year.
A
designated department personal will be responsible for the distribution and
collection of evaluation forms.
Dates:
Each December and June.
Evaluation
will focus on: prompt arrival on time,
Preventive
medicine offered,
Medication
and problem list updated, &
Feedback
from staff and attending physicians:
Medication
Samples and Pharmaceutical Reps:
Please
record, of sample medications the lot number, expiration date, dose &
amount given to the patient on the medication sheet located on inside door of
the medication Room.
Residents
are asked to refrain from taking medications for personal use, as most of our
patients do not have enough money to cover medication cost.
Pharmaceutical
may meet with residents during clinic hours between
Please
note that discussing clinic patients in front of pharmaceutical reps violates
patient confidentiality and disrupts the normal flow of the clinic.
Absences and the protocol to communicate from Department
of Medicine to clinic manger.
Residents
may not cancel clinic or switch days without the permission of the associate
medical Director.
Being post call because of moonlighting or a downtown
elective is not an acceptable excuse to miss clinic. However, post call
residents will be allowed to leave at
All
vacations, interviews, & exam days should be communicated by the CMR to the
clinic 4 weeks in advance via Email. These changes should be communicated
through email and fax to office manager and associate medical director or
medical director.
Residents
should notify the clinic as soon as they discover any change in their schedule,
including any vacations.
Residents
calling in sick should call the physician team supervisor and clinic manager to
notify them of his/her illness.
Prescription
writing:
All
prescription should be written at the time of the patient’s office visit with 4
refills (minimum) for chronic medical problems, to avoid unnecessary paperwork.
A
complete updated medication sheet should be in every chart and the information
should be updated at each office visit.
If
the patient has not been seen in the clinic for more than 6 months, narcotics
should not be refilled.
(Rule #68 state of
Narcotics
should not be refill over the phone unless you the patient is well known to
you.
Your DEA number followed by your beeper number should be written on the prescription pad, when writing for schedule 3 medications eg: Tylenol # 3 and lorazepam etc.
All
PGY- 3 are responsible for refilling the prescriptions in their clinic session.
According
to Medicare rule, not more than 2 prescriptions should be written on one page.
Please review the drug formularies used by the patient’s insurance before prescribing the medication. Patients are charged retail prices for non-formulary medications and usually will not purchase them due to cost.
The following insurance carriers have formularies that are available for review in the clinic.
1. Health
source.
2.
HAP.
3.
4.
Medicaid.
5.
Omni care
If
a patient requires a non- formulary medication, you need to fill a
non-formulary request (prior authorization) form and fax it to the appropriate
formulary service for processing.
Medical
Assistants (MAs)
The
MA staff will be responsible for checking in the patients after initial
registration. They will obtain wt, height, BP, pulse and temperature and do a
pain scale assessment.
Also
at the time of female breast and pelvic exam, they will chaperon in the exam
room.
After
writing your notes and discussing the patient with the supervising physician
the chart should be given to the MA, who will discharge the patient from
clinic.
Appropriate
forms for referrals, lab tests & imaging studies and an encounter form must
be completed for each patient seen in clinic by the assigned resident.
Post
Calls Residents:
All
post call residents from MICU and CCU rotations at
The
following procedure will be followed:
As
soon as monthly schedule is out the CMR will email at least 3 weeks in advance
the clinic manager and medical director about the ICU post call days.
Patients
will be given the option to be seen next week with their usual resident or seen
by the residents.
Residents
on ICU rotation should call the clinic manager at the beginning of the month to
confirm the post call information and reduce the chance of scheduling errors.
CMR: As faculty
Role
modeling: arrive on time and enforce the same standard for all residents.
CMRs
are available to expedite the patient flow in the clinic.
CMRs
will monitored all clinic schedule changes and email the manager and associate
medical director and encourage the residents to periodically remind the clinic
staff.
All
CMR and notes should be discussed with and co-sign by a supervising physician
CMRs
should discourage useless netsurfing and chatting among the residents during
clinic. If one CMR on vacation the other will cover that day and vice versa.
Faculty
responsibilities:
One
attending physician will be assigned as team leader each session of the clinic.
The team leader will arrive on time and communicate any changes for the day to
the residents in clinic and clinic manager.
All
new patients and all patients of PGY-1`s will be seen and examine by the
attending physician.
Faculty
will write a brief note after the resident note as required by Medicare
guidelines and sign both notes.
Attendings
and CMRs will ensure that proper history and physical examination, differential
diagnosis, assessment and plan are followed for each patient.
The
faculty will enforce the updating of the medication list, preventive screening
flow sheet and problem list on all patients.
Faculty
will ensure the proper level of service and diagnosis are indicated on the
encounter form.
The
faculty will arrange for clinic coverage during vacation periods and inform the
clinic director of the details of the coverage plan.
Faculty
will help in expediting the clinic flow and delegate patients to residents as
necessary to ensure smooth clinic operation.
Under
no circumstances can attending physicians can see their private patients in
resident clinic.
Staff
call patients admitted to the medicine faculty will be followed post discharge
by an intern or resident on the ward team, who cared for the patient during the
hospital admission.
Upon
discharge from hospital, uninsured patients should be given a referral list of
city of
Preventive Medicine
Today
effective practice of medicine requires disease prevention and health
promotion. Currently we follow the US Preventive Services Task Force evidence
based guidelines.
As
medicine is rapidly changing we will implement the most updated guidelines
based on evidence.
All
residents should periodically fill the patient learning assessment sheet on all
patients.
Procedures/Tests
The
following procedures and tests can be done at the clinic:
1.
Punch biopsy skin.
2.
Trigger point injections.
3.
chem. strips for urine testing.
4.
UCG urine for pregnancy test.
5.
KOH preparation.
6.
Suture removal.
7.
Knee joint aspiration/injection.
8.
metered capillary blood sugar.
9. EKG.
10.
Peak flow monitoring.
11.
Straight urinary cath to check post-void residuals.
12.
IV starts with Normal Saline/D5w.
13.
Thin prep Pap test.
14.
Rapid strep screen.
Special
situations:
Domestic
violence should be reported to the attending so appropriate agencies can be
informed.
Homicidal
and suicidal tendencies should be evaluated for all depressed patients, if
necessary security or a resident should escort the patient to the
Ambulatory
Research:
Various retrospective and prospective research
topics are available for ambulatory research at the
Q/A
Review.
Charts
will be reviewed randomly assessing compliance with Q/A guidelines and be
reported to the Medical Director and Associate Medical Director. Residents will
receive the feedback about their performance in complying with preventive
medicine guidelines and medical record keeping.
All Q/A Information will be kept by Medical
Director and will be forwarded to Q/A Committee of Department of Medicine if
required.