"Nuts & Bolts 2" - A Guide to the Clinical Years Section 3: Insider's Guide to Inpatient Settings Table of Contents Chart Review: "History Repeats Itself" Many patients are admitted to the same hospital multiple times. From the perspective of the patient's hospital record, this adds up to a tremendous amount of paperwork: order sheets, admission notes, daily notes, procedure notes, OR notes, nursing notes, vital signs, etc. (noninclusive of outpatient notes). So when you're handed a chart that is "Volume 5 of 5," here are some hints: • Get the old chart. The Emergency Room physician may have requested it, but you may have to call Medical Records to have the chart looked up. If there are multiple charts, often only the most recent chart will be sent. Make it your responsibility to get the chart. • Focus on Discharge Summaries. At the conclusion of each admission, the intern or resident dictates a summary of the patient's hospitalization, including important findings, lab values, procedures (diagnostic and therapeutic), etc. The summary is written in a form similar to the admission note. It is usually concise and contains a list of the patient's problems (problem list) at discharge, including the treatment, discharge medications, and outstanding labs/studies that you may need to track down. Most important of all, it is typed so that you do not have to decipher some overworked intern's cryptic handwriting. • Look for a Medical Student's Admission Note. Many patients have been admitted to the University system multiple times and chances are that a third-year medical student from years past has seen the patient. Remember that third-year students spend more time formulating their admission notes (often because attendings go through them with a fine-tooth comb), so this may be the only place in the chart where you will find information such as family history, social history or a complete PE. Specifically for SFVAMC, get to know the computer system well. Old notes/consults/labs are readily accessible from any of their computers. • Look for the Labs. Labs are best reviewed in the computer, no matter which hospital you are at. By finding the most recent values, you can compare them with the information from the current admission. They can help in determining the patient's baseline (e.g., does Mr. Jones always have elevated LFTs and anemia?), as well as in documenting any changes from that baseline. Also, depending on the rules, speaking to the PMD helps them to be informed and can be a great resource to you about the patient's overall story and his baseline. Always look for the baseline for any abnormal labs. Check if a patient recently had a lab scheduled that you want to order (such as ANA or TSH).