Prepared by Dr. Tara Nysoe
Last updated 10/25/10
Student Orientation Guide for the Medicine 601 Clerkship at Providence
Regional Medical Center Everett
Welcome to the internal medicine clerkship at Providence Regional Medical Center Everett
(PRMCE)! We hope that these four weeks with us will be a highly educational and rewarding
experience. This orientation document describes the structure of the rotation, student
responsibilities and expectations, and hospital policies.
Where to Go on Day One—Directions to the Hospital
Please report to the clerkship coordinator, Dr. Tara Nysoe, on the first day of the rotation at 8
AM. The address of the hospital is 1321 Colby Ave, Everett, WA 98201. Take I-5 North to Exit
192 and merge onto Broadway, continue for about three miles, turn left at 13th Street, turn left
into the Rockefeller garage and park in the patient parking area. Take the elevator to P3, then
take the walkway through the skybridge to the 14th Street side of the hospital. Walk past the ER
entrance and enter the hospital through the main doors. Take the escalator to the 2nd floor, walk
down the hall, then take the elevator to the 3rd floor. As you walk out of the elevator, the
Hospitalist Team room is in front of you and to the right--knock on the door. If lost or in doubt,
ask the unit coordinator at the 3rd floor nurses' station, or call the Hospitalist Team Room at 425-
261-4072 (hospitalists' phone) or 425-261-4076 (assistants' phone). You can reach Dr. Nysoe
through the paging service (425-258-7740).
Orientation on Day One
Students will meet the clerkship coordinator, Dr. Tara Nysoe, in the Hospital Team Room at 8am
on day one of the rotation. Dr. Nysoe will review the information in this document and give the
students a brief tour of the hospital. Students will complete paperwork, be oriented to ProvCare
(PRMCE’s computerized medical record system), and will obtain identification badges which
give access to the Team Room and the parking garage. Please bring your license plate number
for the registration form. Of note, after obtaining your parking permit, students may enter the
parking garage from the 14th Street entrance using your badge swipe and park in “Staff Parking.”
General Structure of the Hospital Team at PRMCE
Providence Regional Medical Center Everett (PRMCE) is a large, not-for-profit hospital, serving
as the major medical center for Snohomish County. The mission of Providence is to provide
compassionate care to the poor and vulnerable, never turning away care for those who cannot
pay. The Hospital Team at PRMCE is a growing group of over 40 hospitalists who provide
inpatient care for nearly all patients with internal medicine problems. Each day, approximately
ten daytime physicians report to work at 7am and are assigned to care for a team of 13-14
patients. Another physician serves as the day’s triage doctor, answering calls for admissions
from the emergency department, primary care offices, urgent care clinics, and outside hospitals.
When a new patient is available to be evaluated at the hospital, the triage doctor assigns the
patient to a daytime physician. Each physician sees 1-3 new admissions during the day in
addition to daily rounding responsibilities. Daytime physicians leave the hospital generally
between 5-7pm, signing out their patients to the nighttime physicians (nocturnalists) who arrive
at 4pm, 6pm, 7pm, and 10pm for 8-12 hour shifts. The nocturnalists’ responsibilities include
evaluating new patients and providing care to patients who have urgent issues overnight.
Student Responsibilities
Every four weeks, two students will work with the physicians who care for the patients on Team
S. Students are expected to arrive at the hospital Monday through Friday and pre-round on the
patients they are following, usually around three patients. Rounds with the attending physician
will begin promptly at 8am, during which students will give a brief 1-2 minute oral presentation
at the bedside for each of their patients. During rounds, students will write orders, which must be
reviewed and signed by the attending physician before being placed in the chart. After rounds,
students will write their daily progress notes. In the late morning, there will often be a teaching
session with a medical specialist. Afternoon activities may consist of admitting new patients,
following up on tests and studies, patient and family education, completion of “Simple Cases,”
or other independent study. An exception to the above schedule is the Thursday morning lecture
series at UW, after which students are expected to arrive at PRMCE by 12:30pm and will
informally round with the attending at 2pm. Students should expect to work about 12 hours per
day on average, inclusive of time spent at home doing necessary reading about their patients and
completing write-ups, exclusive of the commute. Students will receive a schedule of activities
from the clerkship coordinator on the first day of their rotation.
Please note that there is one required overnight call during this rotation; students are excused on
the post-call day at 8am. This call night will usually be scheduled on a Friday night. During the
night, each student may admit 1-2 new patients. Early Saturday morning, students will preround
on all their patients, then briefly round with the attending at 7am, with the goal of leaving the
hospital by 8am. Please note that students are encouraged to obtain sleep in one of the call rooms
before driving home if adequate sleep was not able to be obtained the night before.
Please also note that once per month each student will be expected to give a short (10-15 minute)
informal lunch time presentation on a clinically relevant topic of interest, during which all
hospitalists will be invited to eat lunch and hear the presentation. Examples of previous
presentations include a medical literature review of a controversial clinical question (eg. Can a
patient with a peripheral arterial embolism be safely discharged on subcutaneous dalteparin
before the warfarin is therapeutic, or does the patient need to stay in the hospital for
unfractionated heparin?), or a case-presentation of a patient with an interesting diagnosis and a
review of the symptoms, diagnosis, and treatment of that problem.
Caring for Patients
Each student will admit several new patients each week. These may be patients who are referred
from the emergency department, urgent care clinic, or primary care office. The student will take
the patient’s history and perform a thorough physical exam, then take a short time to prepare to
present to the attending at the bedside. The student and the attending will then write orders
together. Each student is expected to complete a write-up of the H&P for the written chart for
three patients per week on average; if a student sees more than three patients in a week,
subsequent patients do not require a write-up of the H&P by the student. Of note, the H&P’s
should be typed and printed, with one copy placed in the chart and the other in the attending’s
mailbox in the Team Room by rounds the next morning; students will not be dictating or entering
information electronically into the ProvCare computer system.
The student will continue to follow the patient until the patient is discharged and will be
responsible for all aspects of the patient’s care. The student should consider him- or herself the
primary caregiver for the patient while the patient is in the hospital, and should strive to know
everything about the patient. The more the student takes responsibility for the patient, the more
fulfilling the experience, and the better the student will develop effective patient-management
skills. Above all, the student should maintain an exceptional educational attitude.
The student should alert the nursing staff to his/her pager number by writing the number in the
orders section of the chart and on the front of the chart. The student should answer calls from the
nurses about his/her patients, then discuss the issue with the attending physician and decide on an
action plan. Of note, students are not permitted to give telephone orders, and any written order
must be signed by the attending before given to the nurse or placed in the chart.
Students should assist in ensuring that patients and staff are aware of their role in patient care by
wearing their white coats and prominently displaying their badge at all times. They should
introduce themselves to patients and families as third-year medical students from the University
of Washington who are working with the attending hospitalist.
Oral Presentations for New Admissions
After your initial evaluation of a new patient admission, you will have a short period of time to
organize your thoughts before giving the oral presentation to the attending. For new admissions,
the oral presentation should be approximately 3-5 minutes in length. The format of the
presentation should conform to the following structure:
Identification/Chief Complaint
History of Present Illness
Past Medical History
Medications
Allergies to medications
Family History
Social History
Review of Systems
Physical Examination
Labs
Studies
Assessment and Plan
The assessment and plan should be organized by problem. For each problem, state the most
likely diagnosis and explain the evidence supporting that diagnosis. You should then name the
next most likely diagnosis and give the evidence for or against that diagnosis, and so on. Then
outline your plan to either further work-up or treat the problem.
Of note, the oral presentation should focus on information that is pertinent to the patient’s current
situation. Pick and choose which information is the most critical to present (ie the pertinent
positives and negatives), and include the rest of the information in the written H&P. The more
focused and brief the oral presentation, the higher likelihood that the presentation will be well-
received.
Before you start your presentation, explain to the patient that you are going to give the attending
a presentation, and that a lot of the medical terminology may be hard to understand, but that
afterwards you will summarize “in plain English” what you said, and invite the patient to
interrupt if s/he hears something that does not sound correct. Then after the presentation, be sure
to give the patient a brief 1-2 line summary of the assessment and plan in laymans terms and
answer any questions.
Oral Presentations for Follow-Up Visits
Follow-up presentations on daily rounds should be 1-2 minutes in length and include the
following elements:
Identification:
“This is hospital day #2 for Mr. X, our 54-year old man with pneumonia.”
Events overnight: In this section, include important events that occurred since yesterday’s
rounds. This is information that is often obtained from the nurse and sometimes requires the
nighttime physician to intervene.
“The patient spiked a fever to 38.3 degrees last night, and the nocturnalist ordered two
sets of blood cultures.”
HPI: This is subjective information that the patient tells you that is pertinent to the primary
problem. If the patient doesn’t volunteer much information, be sure to inquire. Leave data out of
this section.
“The patient had chills overnight, but this is now better. The patient’s cough is less
frequent, but he still has yellow sputum. No chest pain. No shortness of breath at rest, but
he still gets short of breath when getting to the bathroom. Feels overall a bit better than
on admission.”
Review of systems: Ask the patient relevant questions when you preround, and only mention
new or pertinent symptoms in the presentation.
“The patient has no appetite this morning and doesn’t want breakfast. He also developed
loose stools overnight, three in total, watery, nonbloody. No abdominal pain. No
dysuria.”
Physical exam: Brief and focused, include vital signs, general appearance, and 2-4 other body
systems.
“T-max was 38.3 overnight, t-current is 36, BP 124/80, heart rate 75 with a max of 105
overnight, respirations 18, satting 94% on 2 liters of oxygen. In general, the patient is alert and
oriented to person, place, and time, conversant, in no acute distress. His lungs have decreased
breath sounds in the right base with a slight inspiratory crackle, but no wheezes or rhonchi are
heard, and he has no accessory muscle usage. There is no dullness to percussion. His heart is
regular rate and rhythm with no murmurs, rubs, or gallops. There is no lower extremity edema.
His abdomen is soft, nontender, and nondistended.”
Data: pertinent new labs and studies
“White blood cell count today is 8, down from 15 yesterday. The rest of the CBC and the
electrolytes are normal. Blood cultures are no-growth at one day. Sputum culture is still
pending.”
Assessment and Plan: problem-based format. Assess the response to current treatment by
stating if the patient’s problem is improving, unchanged, or worsening, and in what way; and
outline any alterations to the treatment plan. New problems deserve a discussion of possible
diagnoses and a proposed plan.
“Problem number one: Community acquired pneumonia. Mr. X is improving, in that he is
less short of breath at rest, his cough is improved, and his white blood cell count has
normalized on IV ceftriaxone and azithromycin. However, he did still have a fever
overnight, and he has a small oxygen requirement. The plan is to continue the current
empiric antibiotic therapy, watch for sputum culture results to allow us to tailor our
therapy, and plan for discharge in the next few days if he continues to feel better, if his
oxygen requirement resolves, and if he becomes afebrile for over 24 hours.
Problem number two: Diarrhea. This is a new issue, and differential diagnosis
includes…”
Before you start your presentation, please be sure to remind the patient that your presentation for
the attending may be hard to understand, but you will summarize for the patient at the end and
answer any questions.
Writing Orders
Admission orders should be written by the student with the assistance of the attending physician.
The A-D-C-vaan-disml mnemonic may be used:
A-dmit to Team S, student doctor Sue Smart pager 206-555-5555 during the daytime
D-iagnosis
C-ondition
V-ital signs
A-ctivity
A-llergies
N-ursing orders, including call parameters
D-iet
I-VF
S-tudies
M-edications
L-abs
Once a student has been shown to be comfortable with this mnemonic, the student may then use
the Hospital Team’s standardized admission order set to write orders.
When writing orders, avoid the following unapproved abbreviations:
QD (use daily)
QOD (use every other day)
U or IU (use units)
MS or MSO4 (use morphine)
MgSO4 (use magnesium sulfate)
L Lt or R Rt (use left or right)
Leading decimal .25 (use leading zero 0.25)
Trailing zero 1.0 (use 1)
All but emergent orders should be written by the student, including those on admission and
throughout the patient’s hospital stay. The attending physician must sign the orders before being
placed in the chart.
Admission Write-Ups and Daily Progress Notes
The admission write-up is the place to include both pertinent information and all other
information not given in the oral presentation. The write-up should conform to the general
structure of the oral presentation as outlined above. At the top of each H&P, type “MEDICAL
STUDENT HISTORY AND PHYSICAL” in big bold letters, followed by the patient’s name,
date of birth, date of admission, and your name.
ID/CC: Include the patient’s age, gender, and primary presenting symptom (not diagnosis)
HPI: Include all pertinent positives and negatives. If the information you want to include in the
HPI is very complicated, it is usually best to organize the information chronologically.
PMH: List the patient’s past medical problems and give details (last HbA1c for diabetes, cpap
settings for obstructive sleep apnea, last PFTs for chronic obstructive pulmonary disease, last
ejection fraction for congestive heart failure, etc.)
Meds: In addition to listing the patient’s outpatient medications, indicate the source of the
information (eg the patient’s memory, a typed list in the patient’s pocket, the ER chart, the
outpatient record, etc)
Allergies: For each medication, indicate the reaction the patient had.
Family history: List what medical problems the patient’s family members have had and also
indicate specifically if any family members have or have not had a diagnosis relevant to the
patient’s presenting problem.
Social history: List tobacco, alcohol, and illegal drug history as well as the patient’s living
situation, occupation, and any other relevant social history.
Review of systems: List out all systems and list all the pertinent negatives that were asked.
Physical exam: Give vital signs and general appearance, then list by organ systems (pulmonary,
cardiovascular, gastrointestinal, neurologic, skin, etc).
Labs: If abnormal, indicate what the value was the last time the patient had labs drawn.
Studies: Give the radiologist’s read as well as your read if you are able to view the image.
Assessment and Plan: Should be in a problem-based format, with the primary problem discussed
first. Start your discussion by clearly stating the most likely diagnosis and give the evidence to
support the diagnosis. Then, state the next more likely diagnosis and give the evidence for and
against that diagnosis, and so on. In your discussion, be sure that every sentence you write
directly relates somehow to your patient, rather than a book-report type discussion regarding the
diagnosis. For each subsequent problem, be sure to assess the problem at least briefly (eg. 2.
Hypertension-controlled on usual medication) and give the plan. (Plan: continue metoprolol and
amlodipine at usual doses.)
Write-ups should be typed and printed, with one copy placed in the chart and one copy placed in
the attending’s mailbox in the Team Room by rounds the next morning. Please be sure that the
H&P placed in the chart has a patient sticker placed in the bottom right hand corner of each page,
and be sure to initial or sign the bottom of each page.
Subsequent progress notes should adhere to a modified SOAP note format:
MEDICAL STUDENT PROGRESS NOTE (in bold letters at the top of the page)
Patient name
Date of service
Date of admission
Student name
Identification
Events overnight
S-ubjective (history of present illness, review of systems)
O-bjective (physical exam, labs, studies)
A-ssessment
P-lan (combine assessment and plan into a problem-based format)
Signature
These notes may be hand-written or typed. By the end of the day, one copy should be placed in
the patient’s chart and the other copy in the attending’s mailbox. Be sure that a patient sticker is
placed at the bottom right corner of every page of the copy that’s placed in the chart, and be sure
to initial or sign the bottom of each page.
Once per week, please leave a copy of at least one H&P and one daily progress note in Dr.
Nysoe’s mailbox in the Team Room.
Tips for Pre-rounding
It may take up to 30 minutes per patient to thoroughly pre-round each morning. This should
include interviewing and examining the patient; talking with the patient’s nurse about overnight
events; and reviewing the orders and progress notes sections of the chart, new labs and studies in
the computer, current medication list in the computer, and nocturnalist’s cross-cover notes.
Include the pertinent information in the oral presentation, and save the rest of the information for
the progress note. Because it takes time to gather this information, and given that it is expected
that each student be prepared to round promptly at 8am, please plan accordingly when
determining what time to arrive at the hospital.
Medical Specialty Teaching
Students will have many one-hour teaching sessions with various medical subspecialists during
their time at PRMCE, including cardiologists, pulmonologists, gastroenterologists, oncologists,
nephrologists, neurologists, and infectious disease specialists. If a student has a special interest in
any of these fields, or would like to see any procedures in particular such as cardiac
catheterization or endoscopy, please alert the clerkship coordinator. Of note, it is the student’s
responsibility to be on time for these teaching sessions. Please fill out the specialty teaching
session feedback form once per week and place this form in Dr. Nysoe’s mailbox in the Team
Room.
Charting
The ProvCare electronic medical record contains dictated H&Ps, interim summaries, and
discharge summaries by the attending physician, as well as dictated initial consultation notes by
specialists. Subsequent progress notes by attendings or specialists are hand-written and found in
the paper chart. Laboratory results, imaging results, vital signs, nursing notes, discharge planning
notes and therapy notes are all found in ProvCare. Orders are written in the paper chart, and the
medication reconciliation done on admission by the nursing staff is found in the paper chart.
Resources
The Hospital Team Website has useful links such as a “Medical Student Program” link that
contains the student schedule, an “Epic” link for The Everett Clinic outpatient medical record,
and other information. To access the Hospital Team Website from the PRMCE intranet home
page, click on “Medical Staff Website” about half-way down on the left-hand side, then click on
“Hospitalists Web Page” on the upper right-hand side of the next page; this will take you to the
Medical Hospitalist Team website. The link for the medical student program is towards the
bottom of the right side of the page.
Students may use the laptop computers that are set up in the locker area of the Team Room to
review patient data, write their notes, and study. Because the five desktop computers in the front
of the Team Room are often in high demand, students are asked to refrain from using these
computers and instead use the laptops in the locker area.
Student Evaluations
Students will be evaluated by the attendings using the PRIME method employed by the
University of Washington:
Professionalism: compassion; respect for patients, peers, and colleagues; responsibility;
integrity; altruism; and scholarship or educational attitudes.
Reporter: takes excellent history and does an appropriate physical exam; is able to do concise
and excellent presentations and exchanges information very well; this is the expected
competency level for a third-year medical student (Pass).
Interpreter: excellent presentation skills and reliably interprets data to come up with diagnoses
and appropriate differential diagnoses; the differential diagnoses should be weighted to
point out the most likely diagnoses; students functioning at the Interpreter level 75% or
more of the time are at the High Pass level.
Manager: excels as a Reporter and Interpreter, but in addition, routinely suggests appropriate
patient management that shows understanding of the disease process and the underlying
pathophysiology; students functioning at the Manager level 75% or more of the time are
at the Honors level.
Enhanced Communication: explains information to the patient exceptionally well; can discern
when the patient has difficulty understanding what is being explained, and tries other
words and methods.
Students will receive frequent informal feedback from the teaching attending, in addition to
formal feedback from the clerkship coordinator. Patients are also asked to evaluate students by
filling out the “Medical Student Evaluation Form” found on the website. Students are expected
to give a form to each of their patients on the day of discharge; the patient should fill this out,
with assistance if needed, and the nurse should fax it back to the Hospital Team office and placed
in Dr. Nysoe’s mailbox.
National Board of Medical Examiners Internal Medicine Examination
Those students rotating through PRMCE during weeks 9-12 of the internal medicine clerkship
will be released after the morning lectures on Thursday of week 12, the day before the exam, for
independent study.
Pertinent Hospital Policies and Procedures
Codes:
Blue—heart or respiration stops
Red—fire
Gray—combative person
Silver—weapon or hostage situation
Internal Triage—bomb threat
External Triage—external disaster
Orange—hazardous spill
Amber Alert—infant/child abduction
Rapid Response Team—medical team needed at bedside
Universal Precautions and Infection Control:
Please review the information on universal precautions and infection control provided during
first-year orientation as well as at the end of the second year prior to rotating at PRMCE. Links
to this important information can be found on the UW website:
http://uwmedicine.washington.edu/Education/MDProgram/StudentAffairsAndServices/Blood-
borne+Pathogens.htm
Key Contacts
Clerkship Coordinator
Dr. Tara Nysoe
Pager 425-388-2142
Tara.nysoe@providence.org
Hospital Team Assistants
Eloise Reinders, Chris Laffranchi, Jopine Atienza
425-261-4076
Hospital Team Room
Physician’s Line
425-261-4072
Paging Operator
425-258-7740
Ward Numbers (prefix 8- from inside line)
CEU: 4590
3A: 3380
3B: 3395
4A: 3480
4B: 3680
5A: 3390
6A: 4526
7A: 3570
8A: 4390
Laboratory
261-3636
Pharmacy
261-3530
Radiology Reading Room
261-4096
Medical Staff Office
261-4082
Library
261-4090
Roz Winters
Clinical Support Specialist (ProvCare)
317-0195