"Nuts & Bolts 2" - A Guide to the Clinical Years Section 4: Insider’s Guide to Ambulatory Settings Table of Contents Daily Agenda Clinics tend to run from 8 A.M. to 5 or 6 P.M. with scheduled appointment times. Drop-ins occur at the same time and may be added to your schedule especially when you have patients that fail to show. Also, some clinics may be all urgent-care with no pre-scheduled patients. Hours can vary in this setting. As a medical student, you are allocated more time for your patient appointments. They may run anywhere from 30 to 90 minutes for new patients. This varies by site. On average, you are expected to see three to four patients during a half-day of clinic. Rounds They do not exist in the outpatient setting. Occasionally, there are conferences to attend such as Grand Rounds. These settings have lectures built into the schedule where attendance is often required. Please let your clinic know in advance when you expect to be at LCE, conferences, etc. Work Work includes writing a SOAP note for all follow-up patients and sometimes completing a thorough history and physical examination for new patients. Please refer to the section on SOAP notes for more information. Also, be aware that Admission Notes and Orders are not applicable in this setting. You may be responsible for filling out billing forms on each patient you see. These forms will differ at each site and usually require a great deal of skill in checking boxes! Papers are often assigned for each outpatient rotation that will require you to do research and outside reading. Some rotations have other short assignments like family trees, short presentations, and field trips to places like local Alcoholic Anonymous meetings, home care assignments and community projects. Of course, we know you are still reading about your patients too! Charting and Note Writing Charting and note writing, as explained above, are important in the outpatient setting to ensure communication among different providers. Your patients will view you as their doctor in many cases. But remember that you are only at any site for the duration of your rotation, so well-written and legible notes are highly valued. Students write notes after each patient encounter or collectively at the end of the day, depending on attending and student preference. The former is recommended only because you are less likely to forget details for a given patient and you usually get to go home sooner. You can also use your charting as a basis for feedback from attendings. Don't be afraid to ask for input, just remember that each attending has a different style and will want to share it with you. You will find that you develop you own style from their pearls. Remember to be flexible, you may need to modify your note style on an "as needed" basis! It may be helpful to refer to the "Tree of Data Gathering" for guidelines on SOAP outpatient charting. Chart Review Chart review is very important in the outpatient setting because it serves as a primary source of information regarding the patient in front of you. It is wise to review the chart before the encounter if possible. Request any old charts or records for new patients prior to their appointment times if they are not already available. Using the innumerable codes and passwords you are given at each site, try to search for the most recent labs or radiology results in the computer. Many times the charts are not available by the time your patient arrives for an appointment. This will require you to review much of a patient's prior history and physical examination before focusing on the reason for their visit. Try to locate charts before a visit and keep short notes on patients you expect to see again so that you have some clue about the visit. Do you detect a theme here? Do not take charts home, out of the clinic, or hide them even though you may see residents do this! Common Medical Notations F/U = follow-up RTC = return to clinic HTN = Hypertension DM = Diabetes Mellitus H/o = history of C/o = complains of U/S, US = ultrasound PCP = Primary Care Provider (not the drug)