Guides

Guides

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How to efficiently chart review and see/staff consults

1. Add the patient to the appropriate list
2. Put it universal orders: CBC, BMP, Coags (including PTT), ESR/CRP, CXR, EKG, UA, NPO
  • If you are busy and not in front of a computer, ask the person on the phone to put these in but do not trust they will - check yourself later
3. Check a high quality H&P from another service and copy/paste PMHx then filter it
  • take 2 seconds to delete silly diagnoses like GERD, knee pain, skin mole
  • things that matter in neurosurgery: any major cardiopulmonary, renal, or hepatic history? do not copy forward chart lore
4. Check all NSGY operative notes
  • the brief clinical summary that every attending is required to write at top of their op note is actually very high quality and succint (typically)
5. Check prior neurosurgery consult notes
  • don't copy paste but this is a good start
  • good to know patient's baseline exam
6. Check neurosurgery office notes
  • these are often dictated giant blocks of texts that are also copy-forwarded, but the assessment/plan often has the salient information
  • know what the patient's last documented exam was
7. For blood thinners:
  • Ask the patient and family by reading out a very specific list, such as: "do you take any blood thinners? Do any of the following sound familiar: aspirin, plavix, britllinta, warfarin, coumadin, eliquis, xarelto, pradaxa"
    • no one really knows what a blood thinner is, they will often answer you "yes tylenol and coreg" when you ask any blood thinners
    • bonus points for things like Excedrin/Bayer back and body which people take for headaches and back pain and contain ASA81
  • For collateral #1, in Cerner, check "orders" —> External Rx history and see what they've actually filled at outside pharmacies
  • For colateral #2 In Epic, check list of meds and see if any AP/AC listed there
8. Interviewing and examining patient
  • you should generally know what is going on before you talk to the patient, whether that's from chart or the person who called, you should not be fact finding primarily in the room, there is no time for this.
  • it's best to start an interview with "i hear you to hospital for X, is that correct?" rather than ask "what brings you in"
  • minimize the # of open ended questions you ask, this is not medicine, people should have definitive structural diagnoses that can be mapped to your review of systems and focused physical exam.
  • use the universal ROS below in consult tempalte for every single patient.
9. Check the physical patient chart in the ED or on the floor / ICU for direct admits
  • check for H&P - this will often be crucial for patients with no UPMC records who are direct admitted to ICU after a disastrous course at OSH
  • check for reads from outside hospital scans and take pictures
  • check for pertinent labs (e.g. head bleeds that have coags at OSH so you don't have to wait for your EVD)
10. read every single final read on every single image
Timing that you should aim for:
5-10 min of chart review (10 min for the most complex)
5-10 min examining and interviewing
5 min jotting down your notes to the note
How to handle extremely complex consults like a champ
HANDLING VERY COMPLEX ICU CONSULTS WITH PROLONGED HOSPITALIZATIONS AND COMPLICATED COURSES
There is a certain phenotype of consults that can be very overwhelming especially when you're starting. These are typically ICU patients with prlonged hospitalizations  wher it is impossible for you to efficiently review every single consult note and progress note from every service seeing the patient, especially since most of those people are copy-forwarding each other and auto-loading a bunch of junk into their notes.
There is still a solution here that will help you efficiently obtain a comprehensive picture.
Tell the person calling you - ok this is a a very complex patient, I would appreciate your help in giving me a run down of their course and active problems. Make sure you are logged in and actively making a bullet point of things as they talk. Generally the ICU fellows and residents have a pretty good grasp of things.
  • why did they come to the hospital?
  • what are the major things that happened in the interim?
  • While on the phone, review every single medicine and drip and ask about pertinent stuff: why is this person on steroids? Why on ABx? Why on random med?
  • While on the phone, review labs and ask about aberrant stufff. Why is their sodium 119, what is their diagnosis?
  • review MicroViewer and Micro to see what cultures are cooking and what cultures have resulted and what we're doing about that.
  • If they got an LP, know the OP, cell counts,e and glucose/protein
  • how long has the patient been intubated, and for what? Is there a path to extubation?
  • why was the culprit neurosurgical imaging obtained?
  • go through the consult note list and just ask - why was service X engaged and what have they done for patietn?

General Rules for Success

1. Synthesize your H&P -
  • no one is impressed by blocks of texts, we know you never wrote that
  • no one has the attention span for more than 2-3 sentences when reading much less listening to you talk
2. Know everything but say much less than you know - use the barebones template below, let the person you are staffing with ask further questions as needed
3. If you have time, write your note before presenting - this will help you synthesize
4. If you don't know something, admit it., you will be embarrassed to admit it and be tempted to not say that, but believe it or not it's so much more refreshing for your listener to hear "I don't know, but I will go back and check/ask" then it is to hear you beat around the bush or god forbid make something up. You will know what I mean when you start having people staff consults with you.
5. Do one final run through vitals and labs and write them down / put in your consult note template right before you staff the consult. Nothing worse then being asked if someone has a fever and you don't know, it does not instill trust in the rest of what you will say.

Presenting Consults to Chief / Attending

Structure
Example
1. List, to be staffed with attending

2. Patient name, location

3. Why is the patient here?

4. What is their diagnosis / why did they call us?

5. pertinent PMHx / review of systems (be very brief, have information available, but don't spill it out right away)

6. Exam

7. Imaging

8. Plan
Hi chief, I have a consult for Blue list to be staffed with George

Patient is 55 year old Deborah Walters in the ED

She came to hospital for a sudden headache with a history of known pituitary adenoma

There is concern for pituitary apoplexy

Her acuity is 20/50 on the right, 20/20 on the left, has a R 6th palsy but is otherwise wide awake intact with a 10/10 HA

I have a CT only showing small volume hyper-density in the sella

I want to get her a stat MRI pituitary, CAP at 140, get pituitary labs
Consider doing a mini teleprompter for yourself when starting out with the following template. Eventually this will become natural:
Patient Name and age: 47 year old male
Location: in the ED
1 liner: T0 from an MVC
diagnosis: He has an acute 15mm SDH w/ 5mm MLS
exam: He’s GCS 7T
Imaging findings: other than the CTH, pan-spine CT looks negative on my review though pending reads
Plan: Needs an OR now

Consult / H&P Templates

Template
Example
Neurosurgery Attending:
Dx:
IC: (if trauma)
CC:

HPI:

Denies HA, vision changes, speech changes, nausea/vomiting, weakness, numbness/tingling, signs/sx of seizure, bowel/bladder incontinence, saddle anesthesia.

PMHx: denies PMHx
PSHx: ask about brain or spine surger
Social Hx: lives in CITY, occupation LAWYER, iADLs at baseline, ambulates without walker, no tobacco/alcohol/drugs

NEURO EXAM

IMG: Server

ASSESSMENT/PLAN:

Staffed with Chief
Staffed with Attending

Resident Name
Pager #
Neurosurgery Attending: Paul A Gardner
Dx: 2.5cm pituitary adenoma
CC: H1 tunnel vision

HPI: 67F on Xarelto (Afib, last dose 4/20) who p/w

PMHx: Afib, HTN, HLD
PSHx: no brain/spine surgery
Social Hx: retired teacher,
Meds: +Xarelto, no other aspirin, plavix, warfarin, eliquis, brilinta
Allergies: none

NEURO EXAM
EOS
Ox3
PERRL, EOMI, FS, TML
VA: 20/20 | 20/30
VF: bitemporal hemianiopsia
55555/55555
55555/55555
SILT

IMG: PUH
MRI Pituitary w/wo heterogenously enhancing mass R >L cavernous invasion (Knosp 1)

ASSESSMENT/PLAN:
- Admit to NSGY, floor
- Pituitary labs
- ENT c/s
- Optho c/s
- OR plan to follow

Pediatric

Neurosurgery Attending:
Dx:
CC:
INJURY COMPLEX:
HPI: obtained w/ assistance of  at bedside
no AP/AC w/ unremarkable PMHx
PMHx: Denies
PSHx: No brain or spine surgery.
SOCIAL Hx:
FAMILY Hx:  non-contributory
BIRTH Hx:  non-contributory
ANTIPLATELET/ANTICOAGULATION: Denies current use.
MEDICATIONS: Denies chronic medication use
ALLERGIES: Denies known allergens, NKDA
REVIEW OF SYSTEMS:
Constitutional: No sleep disturbance, weight gain or loss.
Skin: No rashes or sores.
Eyes:  No strabismus.
ENT: No ear infections or hearing loss.
Respiratory: No wheezing or shortness of breath.
Cardiac: No chest pain.
GI: No vomiting, diarrhea, or constipation.
GU: No urinary incontinence or urinary tract infections.
Musculoskeletal: No joint swelling or pain.
Neurological: No seizures.
Hematologic/Lymphatic: No frequent or easy bruising
GENERAL EXAM:
Skin:  Warm.  dry.  intact.
Head:  Normocephalic.  atraumatic.
Neck:  Supple.  trachea midline.  no tenderness.  no lymphadenopathy.
Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  no jaundice.
Ears, nose, mouth and throat:  Oral mucosa moist.  No pharyngeal erythema or exudate.
Respiratory:  Respirations are non-labored.
Gastrointestinal:  Soft.  Nontender.  Non distended.
Musculoskeletal:  Moves all extremities
Lymphatics:  No lymphadenopathy
Psychiatric:  Cooperative
NEURO EXAM:
IMAGING: server: CHP
A/P:
      Resident MD
      Pager 2146

      Add-ons (dot phrases)

      Oncology history

      • Dx:
      • Prior systemic tx:
      • Current systemic tx:
      • Known neuro-axial mets and tx:
      • Primary oncologist and last pertinent f/u:

      Bulbar Symptoms

      Denies dysarthria, dysphagia, dysphonia, flaccid facial muscles, hyperactive jaw-jerk, eye movement abnormalities

      Shunts

      • Date of Diagnosis of hydro: congenital vs post-operative vs. post-traumatic vs. post-hemorrhaghic etc.
      • Any history of shunt malfunctions:
        • Radiographic failure: check yourself the preop scans of when patient was revised - do their vents get larger when they fail? Also confirm with the parents although don't expect them to know this or rely solely on it.
        • Clinical failure sx: ask parents what it looks like when their shunts fail. Directly ask them - do you feel their shunt is failing? They usually know best.
      • Any history of shunt infections:
        • if so, what bugs, what ABx used?

      Pituitary ROS

      Corticotroph: denies GI sx (abdominal pain, n/v), weight gain, increasing waist circumference, proximal muscle weakness, easy bruising, skin changes, recurrent infections, easy fractures
      Gonadoptroph: endorses normal libido, has morning erections
      Thyrotroph: Denies heat/cold intolerance, denies fatigue, constipation / diarrhea
      Somatotroph: Denies change in shoe size/ring size, snoring, facial changes
      Lactotroph: Denies galactorrhea
      Posterior pituitary: Denies polyuria and nocturia, excessive thirst

      mJOA

      mJOA myelopathy score: mild 15-17, moderate 12-14, severe 0-11
      Upper motor: 5-hand function intact, 4-hand function mildly impaired (mild difficulty buttoning shirts), 3-hand function moderately impaired (moderate to severe difficulty buttoning shirt), 2-cannot button shirt but can still feed self with spoon, 1-cannot button or feed self, 0 - cannot move hands
      Upper sensory: 3-normal sensation w/o parasthesias, 2-mild sensory loss, 1-severe sensory pain, 0 - no feeling at all
      Lower motor: 7-normal, 6-mild flat instability but no cane/walker/rail use, 5-moderate flat instability, can use stairs w/o rail, 4-can use stairs with rail, 3-can walk flat w/ aid, 2-cannot walk, moves legs, 1-cannot move, can feel, 0-cannot move or feel
      Sphincter (passes urine): 3-no issues at all, 2-mild to moderate issues, 1-severe issues, 0 - no voluntary micturition
      Vascular (1)