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					  PEDIATRIC RESIDENT MANUAL




    DEPARTMENT OF PEDIATRICS

THE UNIVERSITY OF TEXAS AT HOUSTON
         MEDICAL SCHOOL

            2003-2004
Department of Pediatrics                                                                    2



                            POLICY ON RESIDENT ELIGIBILITY


Applicants with one of the following qualifications are eligible for appointment to the Pediatric
Residency Program.

1.     Graduates of medical schools in the United States and Canada accredited by the Liaison
       Committee on Medical Education (“LCME”).

2.     Graduates of colleges of osteopathic medicine in the United States accredited by the
       American Osteopathic Association (“AOA”).

3.     Graduates of medical schools outside the United States who have completed a Fifth Pathway
       program provided by an LCME-accredited medical school.

4.     Graduates of medical schools outside the United States and Canada who meet the following
       qualifications:

               a.      Have a currently valid certificate from the Educational Council for Foreign
                       Medical Graduates (“ECFMG”).

               b.      Have notarized copies of all documents required by the Texas State Board of
                       Medical Examiners (“TSBME”) for an Institutional Permit. These include:

                       1.     Notarized copy of medical school diploma.
                       2.     Notarized copy of certified transcript with grades or marks from each
                              medical school attended. A description of specific course work may
                              be necessary if course titles are different from courses required by the
                              TSBME.
                       3.     Notarized copy of a certification by the Dean of the medical school of
                              the applicant's graduation from medical school.
                       4.     Notarized copy of a valid ECFMG document; or 5th pathway
                              certificate. If ECFMG document valid, through dates must be
                              stamped at the bottom, or can be validated indefinitely, or can have
                              current interim document.
                       5.     Copy of USMLE scores.
                       6.     Marriage Certificate if there is a name change in documents, or a
                              legal court name change document.

Graduates of offshore, non-LCME Accredited institutions must meet the same requirements as
graduates of medical schools outside the United States and Canada. An applicant will be considered
for interview only after he/she provides the above documentation. The appropriate training visa is a

J-1 visa. The Department of Pediatrics as a routine does not support H1-B visas for training.
Department of Pediatrics                                                                3


Applicants who are foreign nationals in U.S. medical schools on an F-1 visa may be considered for
an H1-B visa as an extension of their F-1 visa.
Department of Pediatrics                                                                    4



                        POLICY FOR SELECTION OF RESIDENTS


Applications for PGY-1 resident positions will be accepted only through ERAS. Applications will
initially be reviewed and evaluated based on educational background, academic performance, United
States Medical Licensing Exam (“USMLE”) scores, extracurricular activities, research experience,
and letters of recommendation. Applicants will be invited to interview based on this assessment. A
personal interview is required to be considered for a residency position. The Pediatric Residency
Committee evaluates interviewees based on educational background, academic performance,
USMLE scores, extracurricular activities, research experience, and personal characteristics as
evidenced by their personal statement, letters of recommendation, Dean's letter, and their interviews.
 Applicants are ranked and the rank list is sent to the National Residency Matching Program
(“NRMP”). Pediatric residents at a PGY-1 level are taken through the NRMP.
Department of Pediatrics                                                                     5



             POLICY FOR EVALUATION, PROMOTION, AND DISMISSAL


Residents will receive an evaluation from the faculty for each rotation. Overall performance grades
of Outstanding (5), Good (4), Satisfactory (3), Doubtful (2), Unsatisfactory (1) are assigned. Passing
evaluations are Satisfactory, Good, or Outstanding. An evaluation of Doubtful requires remedial
work as specified by the rotation director. An evaluation of unsatisfactory requires that the rotation
be repeated.

A resident who has more than two non passing evaluations in a year will be reviewed by the
Pediatric Residency Committee. The resident’s performance in its entirety will be reviewed. The
Committee, based on its review, may require that the resident perform remedial work, may require
that the resident repeat the year, or may elect not to renew the resident’s contract for the next year.
Egregious behavior which jeopardizes patient safety is grounds for immediate dismissal.

A resident may appeal the Pediatric Residency Committee’s decision through the procedures
outlined in The University of Texas Health Science Center at Houston Graduate Medical Education
Resident Handbook. The Department of Pediatrics adheres to the grievance and due process policy
set forth in The University of Texas Health Science Center at Houston Graduate Medical Education
Resident Handbook (March 2003).
Department of Pediatrics                                                                   6



                                      POLICY ON LEAVE


Residents at a PGY-1 level have two weeks vacation. Residents at a PGY-2 level and above have
three weeks of vacation. Residents at a PGY-2 and greater level are also entitled to four additional
days conference leave.

Leave in addition to vacation may be taken for illness, death of immediate family member, or family
medical leave. Leave for a maximum of three months may be approved by the Program Director.
Leave for a longer period of time must also have the approval of the Chairman.

Sick leave and Family Medical Leave will be compensated for time equal to accumulated sick leave
plus vacation.

The American Board of Pediatrics (“ABP”) requires 33 months of completed rotations to be board
eligible. A resident who takes more than one month leave in addition to the accumulated two
months of allotted vacation in three years will be required to complete additional months of training
beyond three years to achieve a total of 33 completed months of training in order to be recommended
for board eligibility.
Department of Pediatrics                                                                   7




                     RESIDENT PHYSICIAN IMPAIRMENT POLICY

The Department of Pediatrics follows the Resident Physician Impairment Policy outlined in The
Graduate Medical Education Handbook. The University of Texas Employee Assistance Program
specializes in helping people identify their problems, offers guidance, and helps locate resources
when necessary. The program is available to provide confidential, professional assistance, on a
voluntary basis, to residents at no charge. Their contact number is 713-500-3327 or 1-800-346-3649.

A resident whose performance is impaired by alcohol or drug abuse will be referred for evaluation
and treatment. The resident will be placed on medical leave of absence/sick leave until his/her
treating physician determines that the resident may safely return to work. Continued outpatient
therapy will be determined by the treating physician. The Residency Program will provide time off
with coverage for the resident to attend therapy sessions. The resident will have paid time off equal
to accumulated sick days. The department will pay for the resident's Health Insurance for up to six
months even if the resident is on Leave of Absence without pay. When the resident returns to duty,
he/she will be monitored for at least one year by a monitor chosen by the Program Director. The
Residency Program will provide coverage for the resident to attend meetings, therapy sessions, and
monitoring. The condition, treatment, and compliance will be reported to The Texas State Board of
Medical Examiners in compliance with their impaired physician program.

Residents who refuse evaluation, treatment, or monitoring may be dismissed from the Residency
Program.
Department of Pediatrics                                                                    8




                    RESIDENT EDUCATION AND RESPONSIBILITIES
                             GOALS AND OBJECTIVES

Goals and objectives for each rotation will be provided to the resident. Goals and objectives may be
located on the UT Houston Blackboard website under Pediatric Goals and Objectives. Residents
should review the goals and objectives for each rotation at the beginning of the rotation and sign off
on Blackboard that they have been reviewed.


Procedures/Tracking

Residents must keep a procedure log. Residents must acquire and document proficiency in those
procedures listed as Proficiency required by Residency Review Committee (“RRC”). Other
procedures, listed as proficiencies suggested/required by the Ambulatory Pediatric Association
(“APA”) guidelines should also be documented. Please review the procedures listed in this
handbook as well as on the Blackboard website. Documentation of proficiency in the RRC required
procedures is required to meet the General Competency of Patient Care with respect to technical
skills. The resident must have his/her attending sign off on his/her procedure list each month. The
resident must provide the Program Director a copy of his/her procedure list to be reviewed with the
resident by the Program Director at the twice yearly evaluation meetings and will be included in the
Resident's permanent file. A resident must have documented proficiency in the required procedure
skills to be certified as completing the Residency Program.
Department of Pediatrics                                                                                                      9


                             Table of Technical and Therapeutic Procedures

Residents must demonstrate proficiency in the RRC requirements listed in the table
below. Resident proficiency in the procedures, not listed as required by the RRC, is
recommended by the APA and is encouraged by The University of Texas Medical School-
Houston Pediatric Residency Program.

Definition of categories:*

Level 1, Cognition: Resident is not required to master performance of this procedure, but should
understand how it works and when to use it. (These are generally not performed by the pediatrician in
practice, but may be commonly ordered from subspecialists.)

Level 2, Fixation: Resident is developing skill with this procedure, but is still practicing it and becoming
familiar with its complexities. (Pediatricians use it occasionally in practice, and residents may perform it
sometime during training.)

Level 3, Autonomy: Resident should master the performance of this procedure. (Pediatricians use it
regularly in practice.)

* Whitman, N, and Lawrence, P. Teaching Procedures. In: Surgical Teaching: Practice Makes Perfect, pp. 65-80. Salt Lake City: Univ. of
Utah School of Medicine, 1991.


  Technical and therapeutic                      Cognition        Fixation        Autonomy                RRC                 RRC
  procedures                                                                                         requirement          requirement
                                                 Level = 1       Level = 2        Level = 3            (training)          (exposure)
  Abscess: incision and drainage                                                     X                                         X
  of superficial abscesses
  Abscess: aspiration                                                                   X
  Allergy: shot administration                                        X
  Allergy: skin testing                               X
  Anesthesia/analgesia:                                               X                                                           X
  conscious sedation
  Anesthesia/analgesia: digital                                       X
  blocks
  Anesthesia/analgesia:                                                                 X
  local/topical
  Anesthesia/analgesia: pain                                                            X                                         X
  management
  Arterial puncture                                                                     X                  X
  Arthrocentesis                                                      X
  Bladder: catherization                                                                X                  X
  Bladder: suprapubic tap                                             X                                                           X
  Bone marrow: aspiration/biopsy                      X
  Breast pump use                                                                       X
  Burn: management of 1st & 2nd                                                         X
  degree
  Burn: acute stabilization of                        X
  major burn
  Capillary blood collection (PKU,                                                      X
  hct)
Department of Pediatrics                                                               10

 Technical and therapeutic         Cognition   Fixation    Autonomy         RRC           RRC
 procedures                                                            requirement    requirement
                                   Level = 1   Level = 2   Level = 3     (training)    (exposure)
 Cardiopulmonary resuscitation:                               X               X
 Basic life support (BLS)
 Cardiopulmonary resuscitation:                               X             X
 Advanced life support (ALS)
 Cardiopulmonary resuscitation:                               X             X
 Neonatal advanced life support
 (NALS)
 Cardiopulmonary resuscitation:                               X             X
 Pediatric advanced life support
 (PALS)
 Cardioversion/defibrillation         X
 Central line: use/care                                       X
 Cervical spine immobilization                                X
 Chest physiotherapy                  X
 Chest tube placement                                         X             X
 Circumcision                         X                                                     X
 Conjunctival swab                                            X
 Endotracheal intubation                          X                         X
 Endotracheal intubation: rapid                   X
 sequence intubation
 Exchange transfusion: newborn        X
 Ear: cerumen removal                                         X
 Eye: contact lens removal                        X
 Eye: irrigation                                              X
 Eye: eyelid eversion                                         X
 Eye: patch                                                   X
 Eye: fluoroscein eye exam                                    X
 Foreign body removal (simple):                               X                             X
 nose
 Foreign body removal (simple):                               X                             X
 ear
 Foreign body removal (simple):                               X                             X
 conjunctiva
 Foreign body removal (simple):                               X                             X
 subcutaneous
 Foreign body removal (simple):                   X                                         X
 vagina
 Gastric lavage                                               X
 Gastric tube placement                                       X
 (OG/NG)
 Gastrostomy tube replacement         X
 Genital wart treatment                           X
 Gynecologic evaluation:                                      X             X
 prepubertal exam
 Gynecologic evaluation:                                      X             X
 postpubertal exam
Department of Pediatrics                                                              11

 Technical and therapeutic        Cognition   Fixation    Autonomy         RRC           RRC
 procedures                                                           requirement    requirement
                                  Level = 1   Level = 2   Level = 3     (training)    (exposure)
 Hair collection: tinea                                      X
 Heimlich maneuver                                           X
 Immobilization techniques for                   X
 common fractures & sprains
 Ingrown toe nail treatment          X
 Inguinal hernia: simple                                     X
 reduction
 Intravenous line placement                                  X             X
 Intraosseous line placement                                 X             X
 Liquid nitrogen treatment for                               X
 molluscum/warts
 Lumbar puncture                                             X             X
 Medication delivery:                                        X
 endotracheal
 Medication delivery: IM/SC/ID                               X
 Medication delivery: inhaled                                X                             X
 Medication delivery: IV                                     X
 Medication delivery: rectal                                 X
 PPD: placement                                              X
 Pulmonary function tests: peak                              X
 flow meter
 Pulmonary function tests:                                   X
 spirometry
 Pulmonary function tests:                       X
 perform
 Pulse oximeter: placement                                   X
 Rectal swab                                                 X
 Reduction of nursemaid elbow                                X
 Reduction and splinting of                      X                                         X
 simple dislocations
 Seldinger technique                 X
 Sexual abuse: exam/evaluation                               X
 Skin scraping                                               X
 Skin fold thickness                 X
 Sterile technique                                           X
 Subungual hematoma: drainage                    X
 Suctioning: nares                                           X
 Suctioning: oral pharynx                                    X
 Suctioning: trachea (newborn)                               X
 Suctioning: tracheostomy                                    X
 Thoracentesis                                               X             X
 Throat swab                                                 X
 Tooth: temporary reinsertion        X
Department of Pediatrics                                                               12

 Technical and therapeutic         Cognition   Fixation    Autonomy         RRC           RRC
 procedures                                                            requirement    requirement
                                   Level = 1   Level = 2   Level = 3     (training)    (exposure)
 Tracheostomy tube:                               X
 replacement
 Umbilical artery and vein                                    X             X
 catheter placement
 Urethral swab                                                X
 Vaginal lavage                       X
 Venipuncture                                                 X             X
 Ventilation: bag-valve-mask                                  X
 Ventilation support: initiation                  X
 V-P shunt external taps              X
 Wood's lamp examination of                                   X
 skin
 Wound care and suturing of                                   X             X
 lacerations
Department of Pediatrics                                                                                                    13


                             Table of Diagnostic and Screening Procedures

Residents must demonstrate proficiency in the RRC requirements listed in the table
below. Resident proficiency in the procedures, not listed as required by the RRC, is
recommended by the APA and is encouraged by The University of Texas Medical School-
Houston Pediatric Residency Program.

Definition of categories:*

Level 1, Cognition: Resident is not required to master performance of this procedure, but should
understand how it works and when to use it. (These are generally not performed by the pediatrician in
practice, but may be commonly ordered from subspecialists.)

Level 2, Fixation: Resident is developing skill with this procedure, but is still practicing it and becoming
familiar with its complexities. (Pediatricians use it occasionally in practice, and residents may perform it
sometime during training.)

Level 3, Autonomy: Resident should master the performance of this procedure. (Pediatricians use it
regularly in practice.)

* Whitman, N, and Lawrence, P. Teaching Procedures. In: Surgical Teaching: Practice Makes Perfect, pp. 65-80. Salt Lake City: Univ. of
Utah School of Medicine, 1991.


Diagnostic and screening                    Cognition          Fixation         Autonomy                RRC                  RRC
procedures                                                                                         requirement           requirement
                                            Level = 1         Level = 2         Level = 3            (training)           (exposure)
ADHD home and school                                                                 X
questionnaires
Audiometry evaluation:                                             X                                                             X
interpretation
Behavioral screening                                               X
questionnaire (e.g. Eyberg
Child Behavior Inventory,
Pediatric Symptom Check
List)
Bone age: interpretation                         X
Bone densitometer                                X
Breath hydrogen test                             X
Broncho-alveolar lavage                          X
Colonoscopy / sigmoidoscopy                      X
Culposcopy for sexual abuse                      X
evaluation
Developmental screening test                                                         X                    X
Echocardiogram:                                  X
interpretation
Electrocardiogram (ECG):                                                             X
emergency interpretation
Electrocardiogram (ECG):                                                              x
perform
Electroencephalogram (EEG)                       X
Electromyography (EMG)                           X
Esophago-gastro-                                 X
duodenoscopy
Department of Pediatrics                                                              14

Diagnostic and screening         Cognition   Fixation    Autonomy         RRC           RRC
procedures                                                           requirement    requirement
                                 Level = 1   Level = 2   Level = 3     (training)    (exposure)
Hearing screening                                           X                              X
Language screening test (e.g.                   X
ELM [Early Language
Milestone Screening Test] or
CLAM)
pH probe (Tuttle test)              X
PPD: interpretation                                         X
Physiologic monitoring                                      X
interpretation: cardiac
Physiologic monitoring              X
interpretation: Holter, event
recorder
Physiologic monitoring                                      X
interpretation: pulse oximetry
Physiologic monitoring                                      X
interpretation: respiratory
Physiologic monitoring                          X
interpretation:
Capnometry/end-tidal CO2
Pulmonary function tests:                       X
interpretation
Nerve conduction velocity           X
Radiologic interpretation:          X
abdominal ultrasound
Radiologic interpretation:                                  X
abdominal x-ray
Radiologic interpretation:                      X
cervical spine x-ray
Radiologic interpretation:                                  X
chest x-ray
Radiologic interpretation:          X
cranial ultrasound in NICU
Radiologic interpretation: CT                   X
of head
Radiologic interpretation:                      X
extremity x-ray
Radiologic interpretation: GI       X
contrast study
Radiologic interpretation:                      X
lateral neck x-ray
Radiologic interpretation: MRI      X
of head
Radiologic interpretation:          X
nuclear medicine GI scanning
(gastric emptying: Meckel)
Radiologic interpretation:                      X
renal ultrasound
Radiologic interpretation:                      X
renogram
Radiologic interpretation:                      X
skeletal x-ray (incl. abuse)
Department of Pediatrics                                                          15

Diagnostic and screening     Cognition   Fixation    Autonomy         RRC           RRC
procedures                                                       requirement    requirement
                             Level = 1   Level = 2   Level = 3     (training)    (exposure)
Radiologic interpretation:                  X
skull film for fracture
Radiologic interpretation:                  X
sinus films
Radiologic interpretation:                  X
voiding cystourethrogram
Renal biopsy                    X
Scoliosis, scoliometer
Suction rectal biopsy           X
Tympanometry evaluation:                                X                              X
interpretation
Vision screening                                        X                              X
Department of Pediatrics                                                                    16




                    RESIDENT EDUCATION AND RESPONSIBILITIES
                          CONTINUITY CLINIC/TRACKING

Each resident is expected to attend his/her Continuity Clinic one half day per week at the appointed
time. If a resident wishes to cancel his/her continuity clinic, notice of cancellation must be provided
to the Chief Resident and to the clinic scheduling at least three months in advance. If a resident
does not provide sufficient notice, he/she must attend the clinic or have a fellow resident cover
his/her clinic. Continuity Clinic may be cancelled one day per month if it occurs on an afternoon
when the resident is post-call.

Each PL-1 should see a minimum of 3-6 patients per half day and have a panel size of 50 patients by
the end of the year. Each PL-2 should see 4-8 patients per half day and accumulate a panel of 100
patients. Each PL-3 should see 5-10 patients per half day and have a panel of 100 patients.

Residents must keep a log of patients seen in Continuity Clinic so that their patient panel can be
reviewed by their Continuity Clinic attending and the Program Director. Successful completion of
the Residency Program requires the resident's documentation of his/her activity in Continuity Clinic.
Department of Pediatrics                                                                           17




                                         Policy on Duty Hours1

Duty Hours

Duty hours are defined as all clinical and academic activities related to the residency program,
including patient care (both inpatient and outpatient), administrative duties related to patient care, the
provision for transfer of patient care, time spent in-house during call activities and scheduled
academic activities such as conferences. Duty hours do not include reading and preparation time
spent away from the duty site.

        1. Duty hours must be limited to 80 hours per week, averaged over a four-week period,
        inclusive of all in-house call activities.

All residents will have an average of one day per week free of clinical duties. This will not be a
post-call day. A resident may choose to cluster his/her days off to make a long weekend if the other
members of his/her team agree. Weekend days must be taken as days off, when possible, so as not to
interfere with the educational program. For the General Pediatric Inpatient service, days off should
always be taken on the weekend. For the NICU and PICU services, days off may be taken during the
week so as to ensure adequate personnel on all days. The senior resident is responsible for
coordinating the days off schedule and for showing the schedule to the attending for approval.
Special care should be taken to consider post-call days and clinic days. For example, on a three
person team where on a given day one resident is post-call and one resident has afternoon clinic, the
third resident should not take that day as a day off.

        2. For rotations in the Emergency/Acute Care Centers, individual shifts are 12 hours or less.
        There will be an average of five shifts per week.

In-House Call Duties

        1. Call will be on average every fourth night.

Continuous on-site duty, including in-house call, will not exceed 24 consecutive hours. Residents
may remain on duty for up to six additional hours to participate in didactic activities, transfer care of
patients, conduct continuity clinics, and maintain continuity of medical and surgical care. The six
hour post-call period is for concluding continuity of care activities for those patients who were cared
for while on-call. Didactic activities, such as on-site rounds, program conferences, or self-directed
educational activities, may be conducted during the 6 hour period post-call.




1 The Department of Pediatrics Residency Program’s Policy on Duty Hours complies with the Pediatric RRC’s
policy on the 80 hour work week.
Department of Pediatrics                                                                   18


       2. Afternoon continuity clinics after the resident has had a 24-hour duty period may be
       cancelled up to a frequency of one time per month per resident. Post-call residents will not
       attend other clinics, such as subspecialty clinics.

       3. No new patients will be accepted after 24 continuous hours on duty. A new patient is
       defined as any patient for whom the resident has not previously provided care.

Pediatric Residents will have three no call months, one in the second year and two in the third year.
Medicine-Pediatric Residents will have two call free months in Pediatrics, one in the third year and
one in the fourth year.

Reserve Call Duties

Pediatric Residents will have one reserve call month in each year of training. Medicine-Pediatric
Residents will have two reserve call months, one in the third year of training and one in the fourth
year.

       1. Residents on reserve call are required to take in-house call when a colleague is ill and
       cannot take his/her assigned call. The Chief Resident(s) is responsible for calling in the
       reserve call resident when necessary. If a resident is called in for reserve call, those call
       hours will be counted toward the 80-hour work week.

       2. Residents are required to take Telephone Call one week during each of their reserve call
       months. Telephone Call consists of the resident taking outpatient calls and advising patients
       (parents) on whether or not their child’s condition necessitates a trip to the emergency room
       or can wait until regular office hours. Residents taking Telephone Call are not called into the
       hospital.
Department of Pediatrics                                                                                  19




                                     POLICY ON MOONLIGHTING

A resident may moonlight if he/she has a Texas license (not an institutional permit), if he/she has
his/her own malpractice coverage or is covered by the practice where he/she will be moonlighting,
and if he/she is not in the U.S. on a training visa, such as the J-1 visa, which prohibits moonlighting.
 The Foundation malpractice coverage only applies to clinical work under the purview of the
Residency Program.

Residents choosing to moonlight must have approval from the Program Director prior to
moonlighting. All residents are required to turn in a monthly report stating the number of
moonlighting hours for the month. Residents are expected to complete this monthly report
accurately and truthfully on the basis of their professional honor. If a resident misrepresents the
number of hours spent moonlighting, this will constitute a serious breach of professionalism and the
matter will be turned over to the Pediatric Residency Committee for action.

All internal and external moonlighting hours count toward the 80-hour weekly limit on duty hours.2
Accordingly, moonlighting should only occur during no call or reserve call months.

The Program Director reserves the right not to grant approval for moonlighting activities and/or to
limit an individual resident’s moonlighting activity if said activity interferes with the resident’s
performance in the Residency Program.




2 Internal moonlighting refers to moonlighting that occurs within the residency program and/or sponsoring institution
or the non-hospital sponsor’s primary clinical sites. External moonlighting refers to moonlighting that occurs outside
of the residency program.
Department of Pediatrics                                                                       20




                       General Pediatric Service at MHCH and at LBGH

All residents at all levels must follow all policies and procedures at the institution through which
they rotate.

Responsibilities of the Senior Resident

The senior resident is responsible for coordinating the activities of the entire staff on his/her service.
 The staff typically includes 3 or 4 interns, 3-6 third year medical students, attending physician, and
occasionally a fourth year medical student "Acting Intern." Additionally, the resident should serve as
liaison between the medical team and the nursing and ancillary services. The resident should
independently take a history and examine each patient admitted to the service, and write a note with
his/her own assessment, recommendations and plan of therapy. The resident should also review the
intern's history and physical examination and countersign it. If there is any disagreement with the
intern's findings, the resident should append with the following note: "I am in agreement with the
findings of Dr.___________ with the following exceptions….". The resident and intern together
should discuss in detail the history and physical examination, and laboratory work that bears on the
problems, and should prepare a problem list and plan of management.

In addition to his/her clinical responsibilities, the senior resident has important administrative and
educational functions. He/she assigns all new patients to the interns and medical students, keeping in
mind the needs of the service and the workload of each person. The resident should act as direct
consultant to the interns in all matters pertaining to patient care and therapy. He/she should critically
review all intern and medical student work-ups. The resident is responsible for organizing and
leading work rounds, being sure that he/she personally sees all the patients and that rounds are
completed prior to morning report. The resident should also conduct teaching rounds on days when
the attending physician does not do so. He/she is responsible for keeping attending physicians
informed of all new admissions, deaths, plan for changes in management, and the status of seriously
ill patients. To avoid multiple calls from students and interns regarding the same patient/problem,
most attendings prefer the senior resident to call/page. Clarify this with your attending physician
beforehand.

The senior resident should be thoroughly familiar with ALL patients on the general pediatrics floor
regardless of whose service they are on. All children less than two years of age are automatically
followed by pediatrics.

To improve continuity of patient care on an intern's day off, a list of patients by room number that
includes the intern's name will be required EVERY DAY. These lists will be posted after morning
rounds each day. The list should be treated as private patient data (HIPAA). The senior resident is
responsible for coordinating the "days off schedule" taking into account Continuity Clinic, individual
requests, and post call status, assuring that patient coverage is adequate at all times.
Department of Pediatrics                                                                      21


Responsibilities of the Intern

The senior resident will notify and assign new patients to an intern and student. The intern is
expected to act at the patient's primary care physician.

The intern is responsible for taking a history and performing a physical examination. It is important
to ask the patient who his/her primary care physician is and document this in the chart. A telephone
call to the primary care physician should be made upon admission and on a daily basis thereafter if
desired by the physician. The written history and physical examination must be on the chart shortly
after admission, in no case later than the following morning. As part of the initial examination, the
intern should examine the peripheral blood smear, urine, stains of various body fluids, and x-rays as
clinically indicated for the proper management of the patient. The intern is responsible for writing
and carrying out orders for the initial work-up, therapy, initial and daily care, and for the disposition
of the patient, all under the supervision of the senior resident and attending physician. The intern is
responsible for examining the patient every day and writing daily progress notes. Countersignature
of medical student notes is not acceptable. On and off service notes must be written at the beginning
and end of the rotation. These notes should contain sufficient information to facilitate and
coordinate patient care.

Procedures:

Consent forms are required for the following procedures:

               Lumbar puncture
               Incision and Drainage
               HIV Testing
               Blood transfusion
               Line Placement

Consent forms MUST be signed by the parent BEFORE the procedure.

DISCHARGE/DISCHARGE SUMMARIES:

         The discharge instructions should be discussed with the patient's family and the discharge
sheet must be completed. The discharge summary must be dictated or entered in EMR prior to the
patient's discharge. It should include briefly the reason for admission, the pertinent points of the
history and physical examination, pertinent laboratory and x-ray findings, hospital course,
complications, treatment, final diagnosis, discharge medications and instructions, proposed follow-
up, and the physical condition of the patient at the time of discharge. Copies of the summary should
be sent to the patient's private physician, consultants, and the assigned attending physician for the
hospitalization. Acting interns should dictate the discharge summary when applicable; otherwise, it
is the responsibility of the intern.
Department of Pediatrics                                                                  22



DISCHARGE SUMMARY POLICY

Dictation is considered part of work duties and must be completed in a timely manner. Therefore, no
one should be leaving until all of his/her work is completed, including dictation. This, of course,
does not apply on post-call days when the resident must leave at 1:00 p.m. It is expected that on
non-post call days, residents will complete their dictation before leaving for the day. Accordingly,
no charts should be more that two days delinquent. Attendings at LBJ and MHCH will be
monitoring compliance with discharge summary responsibilities.

Prompt and accurate dictation is a part of medical professionalism and it is important that residents
learn how to manage their time so that they are able to keep their dictation up-to-date.
Professionalism is one of the ACGME's required competencies and the resident's professionalism
will be evaluated by the attendings on a monthly basis and by the Program Director on a twice yearly
basis.
Department of Pediatrics                                                                   23


WORK ROUNDS=WALK ROUNDS: BEFORE MORNING REPORT

Objectives:

      Write orders in a timely fashion to avoid multiple phlebotomies on a patient as well as
       prepare for timely discharge
      Enable nurses to join with team and provide pertinent information as well as become
       knowledgeable of patient plans
      Increase visibility and availability to parent/patient
      Increase visibility and availability to consultants

The senior residents at LBJGH must also coordinate his/her team's activities to assure that the team's
patients in Well Baby Nursery and Low Risk Nursery are seen and that his/her team's follow-up
outpatients are seen on the team's clinic day.

Meetings:

The senior resident should be present at the multidisciplinary meetings to facilitate management and
discharge of complicated patients and at scheduled family conferences.

The senior resident is responsible for getting the team to:

      Grand Rounds every Tuesday at 8:00 a.m.
      Morning Report at 8:00 a.m. Monday, Wednesday and Friday, Radiology rounds at 8:00 a.m.
       on Thursday at MHCH.
      Morning Report every morning at LBJGH

Evaluations:

The attending physician, and senior resident if requested, will meet with each intern and student
midway during the rotation as well as at the end of the rotation to discuss evaluations.
Department of Pediatrics                                                                    24


                    Housestaff Teaching Responsibilities of Medical Students


1.     General
             A.        It is the senior resident's responsibility to orient the medical students to the
                       physical plan of the unit and to their roles on the pediatric team.
               B.      The medical students will be given proper instruction in pediatric history
                       taking and physical examination, and in written documentation (i.e. write-
                       ups). This means direct observation of at least one complete admission and
                       work-up of a pediatric patient by a senior houseofficer.
               C.      The senior resident must also ensure that daily notes are complete and in an
                       acceptable form.
               D.      Correct order writing skills to include the ordering of TPN, IV fluids,
                       pediatric drugs, etc., should also be taught as needed. Students should be
                       instructed to follow the MHCH Medication Ordering Policy.
               E.      Each patient will have an assigned medical student unless instructed
                       otherwise by the senior resident or the attending.
               F.      Extra teaching sessions in the afternoon by the senior resident.

2.     Resident Rounds
              A.    The senior resident will ensure that medical student presentations are correct
                    in structure and content. The junior housestaff will assist and should do so on
                    a daily basis. Every medical student must examine each patient assigned to
                    him/her on a daily basis. The medical students must also have gathered all
                    data pertinent to their patients before morning rounds. This is also expected
                    of the junior housestaff.
              B.    The senior resident should begin rounds promptly with sufficient time
                    allocated not only to gather patient information, but also to review physical
                    findings and clinical correlations with the team.

The housestaff must remember that working with medical students is a time-sharing venture. The
extra time spent in medical student education is ideally offset by time saved in note writing, data
gathering, etc.
Department of Pediatrics                                                                25


                              Responsibilities of the Students

1.    Student call schedule posted in residents' room

2.    Student days off schedule posted in residents' room

3.    Student cross coverage schedule posted in residents' room
      Ex. Monday Rick off….Patients covered by Susan

4.    Detailed sign out should be given for patients covered on days off

5.    Students must do their own H&P's; do not plagiarize the resident's note

6.    Students must examine ALL patients daily (complete physical examination)

7.    Students must write DAILY NOTES preferably by noon

8.    Check laboratory test results in AM and PM

9.    Attend all resident rounds, i.e. work rounds, attending rounds, sign out rounds

10.   Attend all educational conferences, including Grand Rounds and Noon Conferences

				
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