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					Baylor Pediatric Residency
 Policies and Procedures
        (Revised 6/12/07)




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                                              Table of Contents

DEPARTMENTAL POLICIES/PROCEDURES ............................................................... 4
  REPORTING CHANGE OF ADDRESS OR TELEPHONE NUMBER ............................................. 4
  DRESS CODE ................................................................................................................. 4
  TIME OFF ...................................................................................................................... 4
     Unplanned Absence (Illness, family emergency, etc.) ...................................... 4
     ABP rules regarding sick leave and maternity leave ......................................... 5
     Departmental policy on sick leave and leave of absence .................................. 5
     Personal days ................................................................................................... 6
     Unpaid leave of absence .................................................................................. 6
     Time off during electives ................................................................................... 6
     The week off between PL-1 and PL-1 years ..................................................... 6
  REQUEST FOR SCHEDULE CHANGE ................................................................................. 7
  PROFESSIONAL TRIPS, MEETINGS, AND COURSES FOR HOUSE OFFICERS .......................... 7
     PL-1 and MP-1 Residents ................................................................................. 7
     PL-2, PL-3, MP-2, MP-3 Residents ................................................................... 7
     Reimbursement for Expenses ........................................................................... 8
     Registration fees ............................................................................................... 8
     Travel Arrangements ........................................................................................ 8
     Hotel accommodations ..................................................................................... 8
     Special meeting time for “presenters” ............................................................... 9
     Spouses ............................................................................................................ 9
     Payment of overage for professional meetings ................................................. 9
  CALL AND DUTY HOURS ................................................................................................... 9
  DEPARTMENTAL COMMUNITY ACTIVITIES ........................................................................ 10
  MOONLIGHTING AND SUPPLEMENTAL CALL FOR PAY ....................................................... 10
     Internal Moonlighting ....................................................................................... 10
     External Moonlighting ..................................................................................... 13
  MAILBOXES.................................................................................................................. 13
  E-MAIL ........................................................................................................................ 14
  LOANS......................................................................................................................... 14
  POLICY ON SEXUAL HARASSMENT ................................................................................. 14
  PSYCHIATRIC COUNSELING SERVICE ............................................................................. 14
  ANNUAL AND PARKING BONUSES ................................................................................... 14
  CONTINUITY CLINIC ...................................................................................................... 15
  SELECTION OF HOUSE STAFF ........................................................................................ 16
  REAPPOINTMENT OF HOUSE STAFF ............................................................................... 16
  COVERAGE FOR DEPARTMENTAL SOCIAL EVENTS ........................................................... 17
  CURRICULUM FOR FAST TRACKING RESIDENTS .............................................................. 17
TEXAS CHILDREN'S HOSPITAL POLICIES/PROCEDURES..................................... 18
  HOUSE STAFF EMERGENCY RESPONSE ......................................................................... 18
  ADMISSIONS ................................................................................................................ 19
  DISCHARGES AND TRANSFERS ...................................................................................... 22
  CHART CARE ............................................................................................................... 22
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   ACTING CHIEF RESIDENT .............................................................................................. 23
   ORDERS, MEDICATIONS AND PHARMACY ........................................................................ 24
   CODES ........................................................................................................................ 27
   COVERAGE OF AREAS WITHOUT ASSIGNED PEDIATRIC HOUSE STAFF .............................. 27
      Pediatric Coverage of St. Luke’s Labor and Delivery and Nurseries ............... 27
      House staff coverage of GCRC (TCH 10 ) non-research patients .................. 28
   MARTIN I. LORIN HOUSE STAFF LOUNGE AND CALL ROOMS............................................. 29
   CONFERENCES ............................................................................................................ 29
   PAGERS ...................................................................................................................... 29
   LONG DISTANCE CALLS ................................................................................................ 29
   PHOTOCOPY ................................................................................................................ 29
   LAUNDRY..................................................................................................................... 29
   IDENTIFICATION BADGES ............................................................................................... 30
   MEALS ........................................................................................................................ 30
   MEDICAL STUDENTS ..................................................................................................... 31
   PARKING TCH EC AT NIGHT ......................................................................................... 31
BEN TAUB GENERAL HOSPITAL POLICIES/PROCEDURES .................................. 31
   5E - "THE FLOOR" ........................................................................................................ 31
   PEDIATRIC INTENSIVE CARE UNIT .................................................................................. 32
   INTERMEDIATE CARE DESIGNATION ............................................................................... 33
   CHART CARE ............................................................................................................... 33
   NORMAL NEWBORN FOLLOW -UP CLINIC ........................................................................ 33
   PEDIATRIC CLINIC ........................................................................................................ 34
   LABORATORIES ............................................................................................................ 34
   X-RAYS ....................................................................................................................... 34
   BATTERED CHILDREN ................................................................................................... 35
   DAILY SCHEDULE ON THE BEN TAUB INPATIENT WARD .................................................... 35
APPENDIX .................................................................................................................... 35




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                 BAYLOR PEDIATRIC RESIDENCY PROGRAM
                       DEPARTMENTAL POLICIES

                  DEPARTMENTAL POLICIES/PROCEDURES

Reporting Change of Address or Telephone Number

     It is the responsibility of each resident to provide the pediatric residency office with
     current contact information, including home address, home phone number, mobile
     phone number (if available), and non-Baylor e-mail address. Each resident is also
     responsible for providing a list of contacts to be notified in case of emergency. All of the
     above information must be kept current, and the resident should notify the pediatric
     residency office immediately of any changes in the information.

Dress Code

     The manner in which a physician dresses is one of many factors that reflect his or her
     respect for the hospital and for the patients. The manner of dress also has an impact on
     patients’ confidence in the physicians.

     All clothing worn in patient care areas should be clean, neat, well kept, and professional
     in appearance. This includes lab coats and other coverings. The policy applies in all
     patient care areas at Texas Children’s Hospital and Ben Taub General Hospital.

     The following items of dress are inappropriate: any attire with open or exposed mid-
     section; shorts; open toed sandals without socks or stockings; T-shirts and other shirts
     without collars. Tasteful and nicely finished, collarless shirts are permitted for women.
     When scrubs are used, the entire uniform should be worn, top as well as bottom. T-
     shirts under scrubs are appropriate, but a T-shirt under a lab coat is not appropriate.

     All accessory items of dress such as jewelry, belts, and hair braids, should be neat,
     tasteful and professional.

Time Off

          Unplanned Absences (Illness, family emergency, etc.)

           The house officer must notify (by phone or in person; an e-mail, text page, written
           note, etc is not sufficient) the Chief Resident and the appropriate colleague or
           supervisor as soon as possible whenever he/she is ill. If he/she is on call that day,
           the Chief Resident will attempt to rearrange the call schedule. If this is not possible,
           the EC float or resident on backup call will be pulled. It is not sufficient to notify the
           senior resident or clinic staff; the Chief Resident also needs to know so that
           adequate coverage can be arranged. This applies on all days, not just the days
           when the ill person is on call. It also is the responsibility of the resident to notify
           his/her continuity clinic if applicable. (Please also see Policy on House Staff of
           Baylor College of Medicine, especially in regard to a physician’s note for illnesses of
           more than 3 days).


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   Planned Absences (physician appointments, etc.)

    If the resident will be absent the entire day or back up coverage (other than cross
    coverage from other residents on the same rotation) is required, the chief resident
    must be notified as above for unplanned absences. In addition, the faculty member
    responsible for the rotation also must be notified as soon as it is known that a
    planned absence will occur. If a resident knows prior to the start of a rotation that he
    or she will have a planned absence, the faculty member for the affected rotation
    should be notified at that time. The resident should not wait until beginning the
    rotation to notify the responsible faculty member.

    No rotation should be considered optional or expendable. Full participation on every
    scheduled rotation is expected. Every effort should be made to schedule planned
    absences for times that minimize disruption of the rotation. This includes scheduling
    appointments for off days whenever possible. If the planned absence must be
    scheduled in conflict with a rotation, the resident should consult with the faculty
    member responsible for that rotation regarding the least disruptive time to be absent.


   ABP rules regarding sick leave and maternity leave

    The American Board of Pediatrics' policy states that, "any absence from the training
    program such as sick leave, vacation, or maternity leave, that exceeds three months
    during the three years of required training should be made up by additional periods
    of training." The Board will require residents to spend additional time in training to
    compensate for any time beyond a total of three months spent on leave or vacation.
    There are eight weeks of vacation over the three years. That leaves four weeks for
    sick leave, maternity leave or leave of absence. For the Med/Peds residents,
    maximal allowable time missed is two months, in proportion to the total time on
    Pediatrics.

   Departmental policy on sick leave and leave of absence

    Baylor College of Medicine policy permits two weeks of paid sick leave per year.
    Unused sick leave may be carried from one year to the next. The Department of
    Pediatrics, at its discretion, may provide sick leave beyond the Baylor provision, up
    to six months, at which time the resident's disability insurance will take effect.

    The Department of Pediatrics will provide six weeks of paid sick leave following the
    delivery of a child. Note, however, that the ABP requires that any leave beyond four
    weeks must be made up (see C2 above). Additional paid leave is contingent upon
    certification of medical need by a physician. Additional unpaid leave up to a total of 3
    months for all time missed (sick leave plus LOA) will be granted upon request, in
    accordance with the Family Leave Act.

    Paid sick leave beyond one week, or restriction of duties (such as no night call) for
    medical reasons beyond one week, requires written certification by a physician.
    Residents on restricted duty will receive full pay, but when such restriction exceeds
    one week, academic credit will be prorated. For example, situations where the
    resident is able to work but cannot take call will be counted as ¼ time missed.



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    Whenever possible, time lost for LOA or sick leave shall be from elective rather than
    required rotations, even if after-the-fact changes in the schedule are required to
    accomplish this. Any LOA or time missed for other than scheduled vacation or sick
    leave or more than 3 days a year (not cumulative) for approved emergency family
    problems must be made up.

   Personal days

    Baylor provides up to three calendar days per year for urgent personal or family
    problems. Approval of the Program Director is required. Personal days cannot be
    taken for trivial problems and cannot be used as vacation or added to vacation or
    holidays.

   Unpaid leave of absence

    Unpaid leave of absence may be granted, at the discretion of the Department, for
    valid reasons, if scheduling permits.



Premiums for health, dental, disability, and life insurance as well as premiums for the
benefits of any covered dependent(s) must be paid by the resident. It is the resident's
responsibility to inform the GME Office of his/her intent to continue dependent
insurance if applicable, as well as life, dental and disability coverage during LOA.
Failure to do so may result in inadvertent permanent loss of coverage.

   Time off during electives

Electives are important educational activities for which the resident is paid and for which
he or she receives academic credit. Absenteeism from an elective rotation for reasons
other than illness or a valid personal emergency is inappropriate. The chief resident, as
during any other rotation, must approve all time off during an elective.

   The week off between PL-1 and PL-1 years

PL-1 residents who begin duty June 24 have a week off between the PL-1 and PL-2
years. This is not a paid vacation, but rather a one-week hiatus, without pay, between
years that adjusts the first year to 52 weeks. If you are making plans or travel
arrangements, please note that the final workday for PL-1 residents will be June 23. The
seven-day hiatus will be from June 24 through June 30. Those on duty the night of June
23 will work until relieved at 8:00 or 9:00 a.m., June 24. The PL-2 year begins July 1.
Residents who begin the program any date other than June 24 (e.g., July 1, January 1,
etc.) are not entitled to this week off.




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Request for Schedule Change

   Requests for changes in the block schedule must be submitted in writing on the appropriate
   form. Requests for changes must be submitted at least 3 months prior to the month
   involved. This applies to changes in elective or other assignments, vacation time, holiday
   time and professional meeting time. You are invited to discuss such requests with the
   appropriate chief resident prior to completing the form, but all verbal discussions are
   preliminary only. Often, at the time of such discussions, the full impact of the request on the
   schedule will not be known. All requests will be reviewed to ascertain that they are
   educationally and mechanically valid. Please do not expect the chief residents to keep track
   of schedule change requests that are shouted to them as the elevator doors close or
   handed to them on the back of a napkin at Grand Rounds. All requests must be submitted
   in writing on the appropriate form, and are not approved until you have received approval in
   writing! Forms may be obtained in the office of Pediatric House Staff Education. E-mail
   requests are easily missed or lost. Do not submit a request by E-mail.

   Please note that approval of an away elective, schedule change, non-emergency leave of
   absence, or other special arrangements in your schedule by Dr. Feigin or Dr. Ward means
   that the elective or change is educationally appropriate, within the guidelines of the RRC
   and ABP, and is approved by the Department. It does not guarantee that it will be
   mechanically possible to schedule that change or elective at the time that you request--this
   is up to the chief resident. If you request the elective during one specific month, it may not
   be possible to accommodate the request. Obviously, if a number of residents request away
   electives or leaves of absence the same month, we cannot accommodate all of them.

   Changes in shift schedules and continuity clinic day schedules are also subject to approval
   by the chief resident. Any changes made in the schedule without the chief resident’s
   approval may be disallowed.

Professional Trips, Meetings, and Courses for House Officers

   All members of the house staff in the categorical pediatric program will be granted one
   professional meeting for each complete academic year (12 months). Residents in the
   Medicine/Pediatrics program shall be granted a professional meeting by the Department of
   Pediatrics during the first and either second or third year.

   Approval and assignments of meetings, maximal reimbursement and other aspects of travel
   and time off shall be in accordance with current policies of the Department of Pediatrics. All
   meetings must be approved as educationally appropriate by Dr. Ward, and all time off to
   attend a meeting must be approved by one of the chief residents. Time off for professional
   meetings is permitted only during certain rotations.

       PL-1 and MP-1 Residents
      PL-I residents are granted time off to attend one local professional meeting each year.
      The department will pay for meeting registration, transportation, and lodging.
      Reimbursement will require proper receipts. PL-1 residents have the option to forego
      the meeting and receive instead a Major’s Bookstore Gift Card (value $450).

       PL-2, PL-3, MP-2, MP-3 Residents
      The following policy is applicable to all PL-2 and PL-3 residents and those MP-2 and
      MP-3 residents getting their meeting while on pediatrics. These residents are granted
      time off to attend one professional meeting each year. If there is a professional meeting

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other than those listed by the department, within the Continental United States, that you
would prefer to attend, this may be possible. Please contact Dr. Ward regarding this.
PL-2 and PL-3 residents (and MP-2/MP-3 residents where applicable) have the option to
forego the meeting and receive a Major’s Bookstore Gift Card (value $750).

PL-2/PL-3/MP2/MP-3 trips involve a maximum of five days away from duty, including
travel time. Travel days may involve some duty (clinical responsibilities) before leaving
or after returning. For five-day meetings, the resident's travel will cut into actual meeting
days; for meetings of four days or less, travel will be before and after the meeting, but
result in no more than five days away from duty.

   Reimbursement for Expenses

Reimbursable expenses are limited to registration fees, lodging, travel expenses, ground
transportation to and from the airport, and airport parking. Rental cars are not
reimbursable. Receipts are required for all items. They are located on the column in
the house staff office. You must also include badge from meeting and airline boarding
passes. Under no circumstances can an individual be reimbursed for more than actual
expenses incurred.

There is a maximum reimbursement of $750 for PL-1/MP-1 residents and $1,000 for PL-
2 and 3 residents (and MP-2/MP-3 residents when applicable) for their meetings.
Anything above this amount will be the responsibility of the resident. The department
will prepay charges when possible - usually registration and hotel deposits. Airfare is the
resident’s responsibility. Hotel charges will need to be paid by the resident at the time of
the meeting. The department will then reimburse the resident. Original hotel receipts
with a zero balance are required to obtain reimbursement.

   Registration fees

For most trips, the department arranges advanced registration on a group basis. Under
these circumstances, the department processes and sends a single check to prepay as
much as possible for registration. Prior to departure, residents may pick up a letter from
the department confirming that their registration fee has been paid.

   Travel Arrangements

Residents are responsible for purchasing their own airline tickets. Transportation to and
from airports will only be reimbursed with a receipt. Parking at airports in Houston will
only be reimbursed with a receipt, and residents are required to use long term parking
facilities. Maximum parking reimbursement is $6.50 a day. If an individual obtains free
transportation to a meeting, he or she cannot be reimbursed for travel expenses.
Reimbursement for taxis will be permitted only when alternative routes such as public
transportation, hotel shuttles or other shuttles are unavailable. Taxi reimbursement to
the Houston airport will be only for an amount equivalent to the medical center airport
shuttle or long term parking, whichever is greater. Taxi to the airport will be reimbursed
fully only when two or more house officers share the same cab. Rental cars are not a
reimbursable item.

   Hotel accommodations



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      If an individual stays with friends or relatives, rather than at a hotel, he or she cannot be
      reimbursed for lodging expenses. Accurate receipts are required in order to obtain
      reimbursement from Baylor. An itemized hotel receipt (not just a credit card voucher) is
      required. Individuals staying at the hotel at a time other than that booked for the group
      will need to make their own hotel reservations. Under these circumstances, the resident
      will be responsible for all deposits and charges and will then present appropriate receipts
      to the department after the meeting for reimbursement. Advance payments, when
      possible by the department will be limited to those individuals traveling with the group.

      In the case of any individual hotel arrangements that cost more than the group cost
      negotiated by the department the resident will be responsible for the difference in cost.
      Arrangements at a less expensive hotel will only be reimbursed at that rate.

      The budget for these meetings is premised on double occupancy rates. Naturally, if
      there is an odd number of males or females in the group, one or two single rooms may
      be required. Any other resident occupying a single room for personal reasons, or
      because of personal last minute changes, will be personally responsible for one-half of
      the cost of the room.

      Please be advised that bookings by the department are generally at least 60 days in
      advance of the meeting. The department should receive all special requests prior to this
      time at a minimum.

         Special meeting time for “presenters”

      Individuals who have been selected to present a paper (not a poster) at a recognized
      medical meeting may be granted time and financial support to attend the meeting
      providing he or she will actually be presenting the paper. This is contingent upon the
      availability of coverage for the resident's clinical responsibilities.

      Time off will be limited to the day of the presentation and appropriate travel time as
      needed. Any additional time will be at the resident's expense and will count against
      vacation or holiday time.

         Spouses

      If notified prior to group booking, the department will make arrangements for spouses
      traveling with the group, but cannot prepay for the spouse's expenses. If prepayment is
      required by either the airlines or the hotel, the individual and his or her spouse will be
      required to make such payment at the time that the airlines or hotel requires it.

      Spouses or other companions rooming with residents attending the meeting will be
      required to pay one-half of the charge for the room.

         Payment of overage for professional meetings

      When the cost of a professional meeting exceeds the designated limit for departmental
      reimbursement, the overage should be paid by the resident in advance of, or
      immediately upon return from, the meeting.

Call and duty hours

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   Call for any rotation or assignment requiring overnight stay in hospital shall be not be more
   frequent than an average of every third night. Continuous duty assignments on the inpatient
   service shall not exceed 30 hours and on the outpatient service shall not exceed 12 hours.

   On inpatient call, residents shall not accept new patients beyond 24 hrs, but may remain on
   duty for an additional 6 hrs (totaling 30 hrs) to complete care and sign out. However, all
   physicians must recognize that responsibility for patient care is not automatically terminated
   at a specific time. These limitations of continuous duty do not apply to pager call taken from
   home.

   Total duty hours shall not average more than 80 hrs per week for any month or rotation.
   House officers should keep track of hours worked and notify the appropriate Chief Resident
   or the Program Director if they are exceeding these limits.

   Duty hours must be logged in the on-line system found on the resident web page
   (www.bcmpeds.org).

   Any change in call (including back up) must be requested in writing and approved in
   advance by the appropriate chief residents. There are no exceptions to this rule.

   If you do switch call at Texas Children’s with another resident (including back-up call),
   please notify the page operator.

Departmental Community Activities

   All residents are expected to participate in a variety of activities that make up the community
   life of the Department. These activities are in addition to the regularly scheduled clinical
   rotations, but are an important part of the resident’s training program, as well as the
   department’s sense of community. While all residents will not be able to participate in all of
   these activities, it is expected that all residents will participate in at least some.

      Backup call schedule.
      Providing coverage for the intern retreat and other special activities
      Serving on departmental committees, as well as hospital and medical school committees
       as assigned
      Attending House Staff meetings.
      Holding office in the Pediatric House Staff Association
      Supplemental call for pay
      Dictation for pay

Moonlighting and Supplemental Call for Pay

        Internal Moonlighting
       Internal moonlighting refers to those moonlighting activities involving coverage for
       services within the Baylor College of Medicine Affiliated Hospitals Training Program.

       General Rules for all Moonlighters:
       By ACGME regulation, internal moonlighting is counted in duty hours. Residents may
       not participate in moonlighting activities if doing so results in exceeding the 80-hour per
       week average limit on duty hours.
       Moonlighting while on back up call is not permitted.

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Prompt arrival at the designated time is expected. Moonlighting assignments carry the
same degree of responsibility as regular rotation assignments.
General guidelines regarding the moonlighter’s duties are outlined below. Some
flexibility will be required in order to equitably distribute the workload. Common sense
should prevail when determining the activities of the moonlighter on any specific day. If
for any reason the moonlighter and other members of the team cannot reach consensus
on what constitutes a reasonable approach, they should consult with the chief resident.
The common sense “rules” regarding what is appropriate to check out to another
resident apply to moonlighters also.
Moonlighters should not leave before the post-call resident has completed their work.
Moonlighters will be paid at the rates noted below. Additional pay will only be granted
under extraordinary circumstances (such as those requiring the moonlighter to stay
beyond a reasonable period of time [approximately 2pm]). Dr. Ward will make the final
determination regarding additional pay, and any questions regarding this issue should be
directed to him.

-TCH 15-
Number of moonlighters: 1
Schedule: every Saturday
Arrival time: no later than 8:00am
Pay: $300/shift
Prerequisites: TCH 15
Duties: The priority for the moonlighter is to see the off-service patients. If there are
enough off-service patients to make the moonlighter’s workload comparable to the other
residents, then they will only see off-service patients. However, if there are not many
off- service patients, the moonlighter should be assigned some peri-op patients
(preferentially the more straight forward cases). Likewise, if there are a disproportionate
number of off-service patients on the floor, the moonlighter is not expected to see every
one of them.

The residents routinely assigned to TCH should divide up the work prior to the arrival of
the moonlighter. The moonlighter should see any peri-op patients assigned to them
before peri-op rounds. Ideally, during peri-op rounds, the post-call resident will round
first followed by the moonlighter so that the moonlighter can be relieved to also see
his/her off-service patients.

-TCH Level 2 Nursery-
Number of moonlighters: 3
Schedule: every Saturday and Sunday
Arrival time: no later than 8:00am
Pay: $250 each/shift
Prerequisites: TCH Lev 2 Nursery
Duties: It would be wise to show up earlier as rounds may start as early as 8:00am, and
the attending will usually round in the order of which resident has seen their patients first
(with post-call resident always going first). As always, the moonlighters should not leave
before the post-call resident is done with their work.

The residents routinely assigned to TCH Level 2 should divide up the patients to be seen
in an equitable fashion. The moonlighters should see all of the patients normally cared
for by the residents who are off for the day. If one or more of the moonlighters are seeing
a disproportionately low number of patients compared to the other residents, they should
be assigned the least complex patients of the other residents.

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-TCH NICU Level 3-
Number of moonlighters: 1
Schedule: every weekend on the day that 2 of the routinely assigned residents are off
Arrival Time: no later than 7:00am
Pay: $350/shift ($400 for neo fellows)
Prerequisites: TCH NICU Level 3
Duties: The moonlighter should see the post-call team patients of the resident who is
off. They should also assist the post-call resident with any work needed.

-BT Newborn Nursery-
Number of moonlighters: 1-2
Schedule: every weekend on the day that 2 of the routinely assigned residents are off
Arrival Time: no later than 8:00am
Pay: $350/shift if only one person; $200 each/shift if two people
Prerequisites: BT newborn supervisor, or TCH Level 2 and TCH NICU Level 3
Duties: Examine and fill out paperwork on all babies in 3G who are born by noon on the
day you are moonlighting. Fill out POPRAS pages 10, 11, 12, complete the Ballard
exam, and sign the pre-printed admission orders. Please sign the preprinted admission
orders, Ballard exam, POPRAS 11 and where it say’s “Sig” on POPRAS 12 after the first
summary.

Additional duties include:

Help the interns:

If you finish in 3G before the interns have finished their work, help examine the
remainder of the babies in 3A and 3B and complete their paperwork. You should do one
of three things:

If the baby is new (i.e. has not been examined by a physician previously) complete the
exam.
If initial exam has been completed, but the baby is not being discharged that day, write a
daily progress note.
If the baby & mom are ready for discharge, complete POPRAS pages 10, 11 (with all
maternal and infant labs, T/D bilirubin level and risk zone), and 12 along with preprinted
discharge orders. Assign appropriate f/u for the baby (newborn clinic follow up if
necessary and/or a 2-week well child check). Please note that the discharge
documentation requires 5 signatures total.

Answer any questions the interns might have about physical exam findings or discharge
planning.

Round with the interns on their patients and make sure all babies were seen, all
questions answered.

Complete the beeper doc checkout sheet with labs to follow-up on for beeper doc on call
and what to do with specific values.

Take checkout paper to beeper doc (281-952-3643) and enjoy the rest of your weekend!



                                        12
     For more detailed instructions, please refer to the orientation handout entitled
     “Moonlighting in the Normal Newborn Nursery” (available in the Neo Chief’s office at Ben
     Taub and on the residents’ web site [bcmpeds.org]).

     The Neo Chief may be paged (281-952-3642) with any questions.

     -BT Level 2-
     Number of moonlighters: 1
     Schedule: every Saturday and Sunday
     Arrival Time: no later than 7:00am
     Pay: $175/shift
     Prerequisites: BT Level 2
     Duties:

     Some attendings like to round as a team so please be ready to round with them by
     8:15am. You can page the BT Neo chief (281-952-3642) to find out what time the
     attending will round.

     The moonlighter is responsible for the patients of those residents who are off during that
     day. You can find the list of residents who are off and the patients you need to see by
     looking at the “Daily Level 2 assignment” list posted on the board of the Residents room.
     Usually there are pre-printed notes left for moonlighters on the dry-erase board in the
     residents’ room.

     The post-call intern and sometimes the post-call Level 2 third year resident round first.
     After you finish rounds and complete work on the patients you saw, please update the
     “BEEPBEEP” list (found in the R: drive, BT Level 2 nursery folder) and then check out
     the to the day cover person on call (281-952-3643) or the Beeper doc (281-952-3643).

     If you are done early you are expected to help the post-call person; once that person is
     done you may leave.


     Page the Neo Chief 281-952-3642 with any questions.

        External Moonlighting

     Any resident engaged in moonlighting must have a valid Texas medical license, must
     have his/her own medical liability (“malpractice”) insurance, and must have the approval
     of Dr. Feigin. Moonlighting without approval is grounds for disciplinary action.

     Residents must not take supplemental call so often as not to have an average of one
     day a week off or to exceed an average of 80 hours a week on duty. Federal law
     prohibits a resident on a visa from earning more than was declared on his/her visa
     application. Therefore such individuals may not moonlight.

Mailboxes

  House staff mailboxes are located in the office of Pediatric House Staff Education at TCH.
  The office is usually open from 7:30 a.m. until 4:30 p.m. Please check your mailbox at least
  once a week.


                                             13
E-Mail

   All members of the house staff have a Baylor e-mail box. That e-mail address is the one to
   which all official business of the pediatric department will be sent. Therefore, the box should
   be checked at a minimum every 2-3 days.

   In addition, the Baylor Graduate Medical Education Office requests that residents maintain a
   separate commercial e-mail account (e.g. Yahoo or Hotmail). The purpose is to provide a
   back up means of e-mail communication should the Baylor e-mail server fail.

Loans

   Short and long term interest free loans are available to pediatric house officers in need.
   Anyone in need of such a loan should contact Dr. Ward.

Policy on Sexual Harassment

   Both Baylor College of Medicine and Texas Children's Hospital have policies prohibiting
   sexual harassment and delineating the procedure for reporting actions or behaviors that are
   felt to be sexual harassment.

Psychiatric Counseling Service

   A psychiatric counseling service for residents is available through Baylor College of
   Medicine. This service is confidential and residents may avail themselves with or without
   the knowledge of the Program Director.

Annual and Parking Bonuses

   ANNUAL BONUS
   Residents in the categorical pediatric program and those in the combined internal medicine-
   pediatric program are eligible for a bonus (special salary supplement) to be paid on a
   semiannual basis. Residents will not receive bonus pay for more years than required for
   board certification: 3 years for categorical pediatrics and 4 years for combined internal
   medicine-pediatrics. The only exception is for those residents doing additional time as chief
   resident; they will be eligible to receive the bonus for time spent as a chief resident.
   Residents in the combined internal medicine-pediatrics program will receive the full bonus
   provided they are in the program for the entire academic year. Residents on scholarships,
   and residents paid by the military, other sponsors, or other residency program, including
   Baylor programs, are not eligible for the bonus.

   As noted above, the bonus will be paid in two installments, typically in August and April.
   The August bonus covers the July through December time period, and the April bonus
   covers the January through June time period. Residents having missed time (or anticipated
   to have missed time) in excess of 90 days during the period covered by the bonus will not
   receive a bonus check during that time period. Rather, the bonus for that period will be
   included with the subsequent bonus check.

   The bonus will be based on time worked. Therefore, the bonus of any resident on leave
   from training will be prorated for time missed.



                                               14
   Residents starting after submission of the bonus check requests will receive the bonus for
   that period at the time of the subsequent check distribution. For example, a resident starting
   in July after bonus check requests have been submitted for the August distribution will not
   receive a check in August. Rather, they will receive their entire yearly bonus (prorated for
   any time missed) at the time of the April bonus distribution.

   Distribution of bonus checks may be delayed for residents who are delinquent in various
   required functions such as, but not limited to, dictation of medical records and completion of
   continuity and procedure logs.


   PARKING REIMBURSEMENT BONUS

   Residents in the Pediatric and Pediatric/Internal Medicine program whose medical records
   are complete and without delinquency shall receive a yearly bonus equal to the amount
   deducted from their paychecks by BCM for Medical Center parking. This bonus shall be
   distributed after the end of the academic year. If a resident leaves the program with
   incomplete records, all or a portion of the bonus will be deducted and used to pay others to
   complete the records.

   Residents who have incomplete or delinquent medical records or continuity clinic logs shall
   not receive the bonus.

   If at any time during the academic year a resident has seriously delinquent medical records
   (>30 days) and fails to complete said records by 15 days following notification by the
   Director of Medical Education, 50% of the bonus will be forfeited. This process can and will
   be repeated either until all deficiencies are corrected or the bonus is reduced to zero.

Continuity Clinic

   Attendance at Continuity Clinic (CC) is required. Residents are excused from CC when on
   vacation or appropriately scheduled out of town electives or medical meetings. Med/Peds
   residents assigned to Medicine are excused from CC when on ICU and the BT ER.

   Continuity Clinics will be cancelled:
    Categorical Pediatric Clinics: From June 24-June 30, outgoing PL-I residents, incoming
      PL-I residents, and upper level residents on intern supervisory rotations (TCH acting
      chief, Ben Taub ward supervisor, and Ben Taub NICU/Level II supervisor) will not have
      clinics. MLK: per Med/Peds program.
    Juniors’ Day (two Thursdays in August; cancel for categorical and M/P L2s and M/P3s
      on Pediatrics)
    Seniors’ Day (in September or October; cancel for categorical and M/P L3s and for
      M/P4s on pediatrics)
    All Baylor holidays (Thanksgiving, Labor Day, etc.)
      Christmas through New Year’s (break); usually from about the Monday before Christmas
      through January 2, or at least from Christmas through January 2 for Pedi clinics.
      Med/Peds clinic closure per MLK schedule, for Baylor Holidays only.

   If a resident’s continuity clinic is in a private pediatric office, it is his or her
   responsibility to notify that office of which days he/she will be there.



                                                15
   Each resident will be assigned a primary and secondary continuity clinic day. Whenever
   possible, the resident will be assigned to go clinic on their primary day. If that is not possible
   (e.g. due to being post-call), the resident will go on his or her secondary clinic day. In a few
   circumstances (e.g. PICU rotation), it may be necessary to assign a resident to a clinic day
   other than the primary or secondary day. Regardless, the continuity clinic schedule will be
   published in Amion, and it is the resident’s responsibility to be aware of the specific day to
   which he or she is assigned for any particular week.

Selection of House Staff

   Selection of house officers shall be nondiscriminatory (e.g., not influenced by race, gender,
   age, religion, disability, color or national origin). Selection of house officers shall be based
   upon preparedness, general ability, intellectual ability, aptitude, academic credentials, fund
   of knowledge, communication skills, interpersonal skills including ability to work as part of a
   team, clinical skills and abilities, motivation, sense of responsibility and work ethic, moral
   and ethical character, and integrity, as well as an applicant’s career goals and the
   Department’s needs.

   These attributes shall be judged by examination and review of applicant's pre-clinical and
   clinical grades, Dean's letter of assessment, individual letters of recommendation, reputation
   and degree of excellence of applicant's medical school, class standing, USMLE scores,
   professional and personal accomplishments and personal interview by various faculty
   members.

   The Department requires that all candidates must have had some experience in an LCME
   approved medical school or in an ACGME-approved residency program. The length, depth
   and quality of such an experience, as well as an evaluation of the candidate’s performance
   during that experience, will be taken into account.

   If the applicant is not a US citizen, he or she must be in possession of a work permit or
   green card, or have or be eligible for a J1 visa.

   If applicable, the applicant must be in possession of a valid ECFMG certificate, or show
   documentation that he or she has met all requirements for ECFMG certification and provide
   assurances that he or she will be able to submit a notarized copy of a valid certificate to the
   Texas Medical Board when required.

Reappointment of House Staff

   House officers are to be evaluated fairly and objectively on the basis of their academic and
   clinical performance, and their ethical and professional behavior. There is a written formal
   evaluation of each house officer for each rotation. Copies of all evaluations are distributed
   to the house officers in a timely manner.

   Reappointment and promotion is on the basis of satisfactory academic and clinical
   performance and continued demonstration of professional and ethical behavior. Each
   house officer's performance is reviewed by the House Staff Selection and Evaluation
   Committee, which makes a recommendation for or against reappointment and promotion to
   the Director of House Staff Education. The final decision for reappointment and/or
   promotion rests with the Chairman of the Department of Pediatrics.



                                                16
Coverage for Departmental Social Events

   The Department will try to provide coverage for residents at all levels attending the end of
   the year house staff banquet. Coverage is provided for individuals on call, with the
   understanding that they will attend the banquet. Those accepting such coverage are
   obligated to attend.

   The Department will try to provide coverage for interns attending the intern retreat.
   Coverage is provided for interns on call, with the understanding that they will attend the
   retreat. Those accepting such coverage are obligated to attend. The Department will try to
   provide coverage for interns attending Dr. Feigin’s Welcome Barbecue and Swim Party in
   July. Coverage will be provided for interns on call, with the understanding that they will
   attend the party. Those accepting such coverage are obligated to attend.

   We regret that it is not possible to provide coverage for the house staff party in January or
   February and the Houston Pediatric Society Dinner/Dance in February. Since not all house
   staff choose to attend these functions, we encourage individuals to switch call whenever
   possible to permit those wishing to attend to do so. Switches must be requested in writing
   and approved by the chief resident.

Curriculum for Fast Tracking Residents

   Residents who have an established track record in research, aside from projects done
   during the four years of college and four years of medical school, may be eligible to petition
   the Board to enter fellowship after two years of pediatric residency. Except in very unusual
   circumstances, this means a Ph.D. degree in addition to the M.D. degree. The department
   has the option of supporting or not supporting the application based on the resident’s
   credentials and performance in the program. The completed application, including support
   letters from the Pediatric Department Chairman and the head of the fellowship program,
   must be sent to the Board before the end of the internship year.

   The following rules shall apply to all residents entering fellowships after two years, including
   those entering neurology.

   No electives shall be taken in the subspecialty into which the resident is going. (This is an
   ABP requirement.) All electives must add to the resident’s experience in general pediatrics
   and be approved by the program director.

   The second year of residency for these individuals shall be modified so as to include a
   month in the TCH PICU and a month as supervising resident on the Ben Taub general
   inpatient service.

   The rotation in cardiology shall be included, since there is almost no cardiology in the
   curriculum otherwise. Also to be included are TCH NICU, TCH Level 2 Nurseries, one
   month as TCH EC, BT EC and TCH Acting Chief.

   Two electives shall be maintained but restricted as below.

      There shall be no away electives. The resident to the House Staff Selection and
      Evaluation Committee will permit exceptions to this rule only upon formal written request.
      Such exceptions shall be based upon a record of sufficient excellence in general


                                                17
     pediatrics to assure that the resident will be appropriately trained at the end of two years
     and upon the necessity, appropriateness and uniqueness of the away elective.

     All electives must be clinical pediatrics. Non-clinical electives such as pathology,
     radiology, etc. will not be permitted. Non-pediatric electives such as anesthesiology,
     ophthalmology, etc. will require the approval of the Program Director.

     The requirement for a primary care ambulatory elective shall be waived, but the 50%
     total ambulatory time rule shall apply. To this end, at least one of the two electives will
     need to be in an ambulatory setting.

  See ABP policy regarding attending Continuity Clinic for one year during the fellowship and
  taking night and weekend call in general pediatrics for one year during fellowship.

       TEXAS CHILDREN'S HOSPITAL POLICIES/PROCEDURES

House Staff Emergency Response

  FIRE EMERGENCY OR FIRE DRILL

  DO NOT SHOUT "FIRE" UNDER ANY CIRCUMSTANCE!
  Rescue        The safety of the patient comes first. If a patient is in immediate
                danger, remove the patient to safety before doing anything else.

  Alert              1. Activate fire alarm system by pulling the closest fire alarm pull
                        station.

                     2. Report the fire to the Hospital Operator at extension 3333. Tell
                        the Operator:

                          WHERE the fire is located;
                          WHAT kind of fire it is;
                          HOW LARGE a fire it is;
                          YOUR NAME and EXTENSION

  Confine/           1.   Confine the fire by closing windows and doors.
   Extinguish        2.   Try to control the fire by using the proper extinguishers.
                     3.   Always stay between the fire and the way out to safety.
                     4.   Crouch low to avoid smoke and heat.
                     5.   Aim the extinguisher at the base of the flames.
                     6.   Avoid inhaling smoke and fire gases.
                     7.   Discontinue oxygen or gas and disconnect electrical appliances
                           in immediate area

  Evacuate           1. If fire and smoke are contained to one section of the floor,
                         patients and visitors shall be moved horizontally toward an exit
                         and to an area that places the smoke doors between them and
                         the danger area.

                     2. If the fire or smoke is out of control and spreading rapidly, it may
                         be necessary to evacuate the floor or entire building. When
                         vertical evacuation is necessary, movement shall be toward the
                                              18
                          first floor. Stairways shall be checked prior to entry and if smoke
                          filled or obstructed, an alternate exit shall be used.


  DR. PYRO, STAT         A fire has been reported in the hospital. The Operator will follow this
                         call with the exact location of the fire.

  DR. PYRO, ALL The fire is extinguished, and it is safe for departments
   CLEAR        to return to normal operations.

                    OR

  DR. PYRO, ALL             The fire drill is completed.
  CLEAR

  DISASTER RESPONSE

  In the event Texas Children's Hospital initiates its disaster response plan, a "CARLA
  ALERT" will be paged.

  Complete on-going patient procedures as quickly as possible.

  Residents on duty should report to the area to which they are assigned and await further
    instructions.

  Residents in the hospital on elective assignment or not on duty should report to the pediatric
    house staff office if it is open, or else to the emergency room.

Admissions

  The Department of Pediatrics of Baylor College of Medicine assigns clinical duties for
  Baylor Pediatric residents at Texas Children’s Hospital. The ONLY patients for whom
  Pediatric house staff are the primary residents, and the ONLY patients for whom they
  should write an admission history and physical are patients admitted to a pediatrician
  member of one of the Texas Children's Hospital Department of Medicine Services
  listed below:

  Adolescent Medicine Service     Infectious Disease Service
  Allergy and Immunology Service Intensive Care Service
      Cardiology Service Neonatology Service
      Dermatology Service Neurology Service
      Developmental Pediatrics Service Nutrition & GI Service
      Endocrine-Metabolism Service        Pulmonary Medicine Service
      General Medicine Service    Renal Service
      Genetics Service    Rheumatology Service
      Hematology-Oncology Service

  PEDIATRIC HOUSE STAFF ARE INVOLVED IN THE CARE OF PATIENTS ADMITTED TO
  OTHER DEPARTMENTS OR SERVICES (SUCH AS SURGICAL SERVICES, FAMILY
  PRACTICE, ETC.) ONLY IF A MEMBER OF ONE OF THE MEDICAL SERVICES LISTED
  ABOVE CONSULTS ON THAT PATIENT OR IS CO-ATTENDING. For these patients,
  Pediatric house officers will be involved in patient care as invited to do so by the admitting

                                              19
service or the Pediatric consultant. The house officer's role in these cases shall be limited to
that of assisting the pediatric consultant or co-attending. The Pediatric house officer will not
be responsible for maintaining the medical record, will not write an admission history and
physical, and will not be responsible for discharge planning. He or she may write daily
progress notes depending upon the circumstances, but he or she will not be responsible for
the definitive daily note or the discharge note. Pediatric house staff will not respond to
nursing questions about these patients except in emergencies or in regard to the issues for
which Pediatrics has been consulted.

An exception to this policy is patients in the PICU who are admitted to a member of the
Department of Surgery, in which case even if there is no pediatric attending assigned to the
case, the pediatric house officer is to be a part of the care team by writing daily notes.
Writing of orders is to be done by, or under the direction of, the physician of record or his
designee.

Please be aware that, except in emergency situations and in the PICU, pediatric house
staff cannot be involved in the care of patients admitted to other services that have
not formally obtained Pediatric consultation or assistance at the attending level. Just
as a Pediatrician could not ask a Neurosurgical resident to care for one of his patients
without formal Neurosurgical consultation at the staff level, so other services cannot expect
pediatric house staff to be involved in the care of their patients without formal consultation.
Emergencies, of course, constitute an exception to this.

In order to meet the 80-hour per week and 30-hour call rules for residents, the following
additional policies have been implemented.

The pediatric residents do not cover patients admitted primarily for surgery even if admitted
to a pediatrician or transferred to a pediatrician for routine postoperative care. The pediatric
house officers’ involvement in the care of these patients is limited as follows.

If requested, the pediatric house officer will assess the patient to determine what, if any,
pediatric problems need to be addressed. If such problems are identified, the pediatric
resident will follow the patient for those problems in conjunction with the pediatric attending,
whether a generalist or sub-specialist. The pediatric resident will not assume total care of
these patients nor will he/she respond to all nursing inquiries. The pediatric resident will be
responsible only for addressing specific pediatric problems that are felt to be outside the
realm of the pediatric surgeons. The pediatric resident will not be responsible for writing
either the admission history and physical nor daily progress notes for these patients. At
most, the house officer will write a brief consultative note addressing the specific problems
for which pediatrics has been consulted. The pediatric resident will not be responsible for
writing daily orders, facilitating discharge planning, or writing discharge orders.

For example, if a post-operative patient develops seizures or renal failure, and an
appropriate pediatric consultation is obtained, pediatric house staff will follow that patient
with the consultant for that problem. The pediatric house staff will not take over the primary
care of that patient.

If a surgeon obtains a pediatric consultation to assist with TPN orders, the pediatric house
staff will be involved in regard to those orders. However, the pediatric house staff will be
responsible for daily TPN orders on such patients only if the pediatric attending or fellow
consultant supervises the resident on a daily basis. This means that the attending or fellow
must also follow the patient and supervise the resident on a daily basis in regards to

                                             20
management of TPN. Under these circumstances, the pediatric house Officer will be
responsible for TPN orders, TPN labs and TPN monitoring but will not be responsible for a
daily note and will not be responsible for problems with lines, fever, etc.

Please see the document “Coverage of surgical and other special patients,” which list
some of the many scenarios that can occur in regards to these patients. This
document is available on the Residents’ Web Page.

PRIVATE PATIENTS: After the intern has evaluated the patient, the private physician must
be called. At night, if it is clear that the EC staff had discussed the admission with the
attending, and the patient’s status has not significantly worsened since admission, and there
are no new critical lab results, the call to the attending physician can be held until the next
morning.

The intern should discuss his/her findings, presumed diagnosis, differential diagnosis, and
proposed therapy with the private pediatrician. All examinations, consultations, and modes
of therapy should be discussed with and agreed upon by the private pediatrician. This
contact serves many purposes. It notifies the attending physician that his patient has been
admitted and that the initial assessment by the intern is completed. It provides an
opportunity for the resident and the attending to discuss the patient and the orders to be
written. It also affords an opportunity for the intern to inform the attending of any changes in
the patient's status since the attending as well as the results of any laboratory data that may
be available last saw the patient. Additionally, it provides a chance for the attending to
provide the resident with medical information that might not have been available via the
parents and patient, and also the attending's assessment of the family and any potential
psychosocial or socioeconomic problems.

Following this, a note should be placed in the patient's medical record, stating that the case
had been discussed with Dr. "John Doe" who agrees with the plan. This sentence should
include both the time and date and should be signed by the intern. If the admitting physician
cannot be reached, the intern should place the following sentence in the chart: "Call to Dr.
Smith placed."

In the case of a patient admitted to the surgical service with a pediatric consult or a pediatric
co-attending, the intern should contact the pediatrician of record, who can then discuss the
case with the surgeon if necessary.

The importance of this initial contact cannot be overemphasized, day or night. In the
situation in which laboratory data is pending, the intern should exercise judgment in deciding
whether or not to call the attending physician immediately upon completion of the history
and physical or after the laboratory data has been returned. Obviously, this decision will
depend both upon the nature of the laboratory data pending (spinal fluid versus CBC, etc.)
and the time of day or night (it would be preferable to awaken the physician once in the
middle of the night with the data, rather than twice, once to tell him the test was done and
the second time to give him the results).

If you anticipate a significant delay before you will have time or opportunity to work up a
patient, you should "eye-ball" the patient and contact the private physician informing him/her
of the anticipated delay and discussing any stat or urgent needs, either diagnostic or
therapeutic. In all cases, preliminary orders for diet; obvious lab work and medication
should be written as soon as possible, sometimes before the history and physical are
complete.

                                             21
  It is the responsibility of the house officer assigned to each patient to know the current
  status of that patient, i.e. changes in the daily physical exam, test results, pending lab
  studies, and to keep the attending informed of any significant changes or new
  developments. Major problems at any time should be discussed with the attending
  physician after any urgent needs of the patient are attended to. The PL-I should discuss
  any patient management problems with the ward resident and the private pediatrician. The
  discharge summary is the responsibility of the private physician.

  BAYLOR FULL-TIME FACULTY PATIENTS: After the intern has evaluated the patient, the
  admitting sub-specialist attending or fellow should be contacted to discuss the findings,
  differential diagnosis, and proposed therapy. All examinations, consultations, and modes of
  therapy should be discussed and agreed upon by the sub-specialist. Discharge summaries
  are the responsibility of the subspecialty service.

Discharges and Transfers

  It is imperative that patients not be discharged without proper arrangements for follow-up. In
  the case of private patients this means that the private physician of record must be aware of,
  and agree to, the discharge. It is not sufficient that a consulting (subspecialty) service or
  consulting attending agree, the physician of record (admitting physician) must agree.
  Whenever possible, try to facilitate discharges early in the day.

  Upon discharge, patients should be given an appointment for follow-up, or be instructed
  specifically whom or where (private doctor or clinic) to call for an appointment. They should
  be provided with necessary medications or prescriptions, as well as instruction regarding
  diet, activity, etc. A "discharge note" should be written in the chart detailing these
  arrangements.

  When transferring a patient from one floor or unit to another, the house officer must write an
  appropriate transfer note, orders, and also should contact the resident receiving the patient
  to discuss the patient's problems and therapy. This is an important part of patient care. The
  resident or intern receiving the patient needs to review the transfer orders and make
  changes if indicated. A patient should never be transferred without a physician's (resident or
  attending) order. Transfer notes should summarize, detailing immediate future needs of the
  patient. A more complete familiarity can await the receiving resident's chart review.

Chart Care

  The chart (medical record) reflects the quality of care given the patient. In order for
  consultants and others to help in caring for your patients, you must provide up-to-date
  information, specifically problem lists, progress notes, and lab flow sheets. All charts should
  include the following:

  Date and time all chart entries -- orders and progress notes.

  1. Admit note (see Appendix) - The length and detail of the history and physical will vary
  depending on the patient and clinical problems. However, all physical examinations should
  include vital signs, blood pressure measurement, height, weight, and head circumference.
  A notation in parentheses of the percentile for age should follow each of these
  measurements. The "Assessment" portion of the admit note is the most frequently
  neglected area. Impressions should be listed according to the problem-oriented format. A

                                              22
   brief list or discussion of the differential diagnosis should follow. The "Plan" should list work-
   up and therapy in a logical manner.

   2. Progress notes - a problem-oriented approach should be used. Each daily progress
   note should contain information, which will aid the professional staff in the care of the
   patient. It should also be complete enough to give a consultant a clear understanding of the
   patient's problems and progress. Start each note with the number of days the patient has
   been in the hospital, e.g. "Day 4 – Post-op Day 2." Include a list of the patient's major
   medications in each daily note, e.g., "ampicillin and cefotaxime - day 9." List pertinent
   physical findings; these will vary with the patient's problems. Under the "Assessment"
   section of the progress note it is important to list the patient's current problems, with
   discussion of each problem's current status. It is unacceptable for the entire assessment to
   consist of, "Stable," or, "Doing well." The note should end with a plan; this should include a
   list of pending labs, etc.

   3. Growth chart - Each chart should have a growth chart with the patient's growth
       parameters plotted.

   4. The medical record is a legal document. Please remember that once a statement is
       written in the chart, it cannot be removed. The medical record is not the appropriate
       place for accusations or judgmental statements. There are many different, yet
       acceptable, ways to manage most clinical problems. If a resident disagrees strongly
       with the management of a patient as requested by another physician (a senior resident,
       private attending, consultant, etc.), this disagreement should not be advertised in the
       chart. It is sufficient to write, "Ampicillin per Dr. John Doe," or "Ampicillin discontinued
       at the request of Dr. John Doe." It is not necessary for a resident to state that he/she
       personally disagrees or would have preferred a different mode of therapy.

        Residents often have occasion to ask individuals not officially involved in a case for
        information or suggestions. In a teaching program such as ours, residents are
        encouraged to ask for information regarding a specific disease or condition from any
        member of the Baylor faculty. Such information, however, does not constitute a
        consultation and should never be quoted in the medical record.

Acting Chief Resident

   At night, on weekends, and whenever the Chief Resident is not in house, the resident on call
   for TCH 9-14 is designated as Acting Chief Resident. The Acting Chief Resident's duties
   include those normally handled by the Chief Resident. All problems, both administrative and
   patient care related, should be directed to the Acting Chief Resident from 5:00 p.m. until
   8:00 a.m. and on weekends. The Acting Chief Resident carries a special "acting chief
   beeper" as well as his or her regular beeper, and may be reached at any time by dialing
   832-824-2099. Additionally, the Chief Resident is always available by pager.

   If problems arise regarding patient assignment, the Acting Chief should contact the Chief
   Resident. The Acting Chief Resident is useful as a resource for information --
   administrative, diagnostic, and therapeutic.




                                                23
Orders, Medications and Pharmacy

   GENERAL.

   All orders should be succinct, clear, and legible, and include the date and time. Include
         patient’s weight. For all orders, include the generic name of the drug, the dose in
         units of weight or activity (mcg, mg, grams, units), the frequency, and the route of
         administration, the dose in mg/kg or mcg/kg, and when an oral liquid is prescribed,
         the concentration (mg/ml) and the dose in units of volume.

        Example: Digoxin elixir 100mcg (50mcg/ml x 2ml) po q day (10mcg/kg/day)

   Once the yellow copy of the order form has been removed, the original order must not be
       changed, marked-over, or altered in anyway.

   Express doses, which are less than 1 with a zero preceding the decimal point (0.1).
       Express doses consisting of whole integers without a decimal point (10, not 10.0).

   Write explicit directions for prescriptions. Avoid using abbreviations. For example, "AZT"
        may be interpreted as zidovudine, azathioprine, or aztreonam.

   Orders written by medical students must be immediately co-signed by an authorized
       physician.

   Verbal (telephone) orders from an authorized physician may be implemented in an
       emergency situation, if received and transcribed to the chart immediately by a licensed
       (RN) nurse or pharmacist. The physician must sign the order within 24 hours. Since
       verbal orders can be misinterpreted, the verbal order process should only be used
       when necessary.

   TEXAS CHILDREN'S HOSPITAL FORMULARY:

   Generally, medications used in the institution will be limited to those that are included in the
      Hospital's Drug Formulary. However, occasionally the use of a medication not
      included in the formulary will be in the patient's best interest.

   The Hospital's Drug Formulary also contains pediatric drug doses. In general, the doses in
       the formulary should be followed in preference to other sources such as the Harriet
       Lane.

   The Drug Information Center is available Monday through Friday 8:00 a.m. to 5:00 p.m.

   PRN AND ON CALL ORDERS:

   PRN orders must be explicit and include the frequency and indication for
        administration. The abbreviation "on call" must be qualified for location or
        circumstances.

        Example: Morphine 1mg IV every 4 hours prn pain.
                 Cefazolin 500mg on call to the operating room.

   TPN-LIPID ORDERS:

                                               24
TPN-lipid orders must be rewritten daily and be in the pharmacy by 2:00 p.m. (preferably by
      noon). If there are no changes in the order from the previous day, you may write
      "same as (insert date of last order)" in the comments section.

TRANSFER ORDERS:

All medication orders shall automatically be canceled when a patient enters or leaves
      an intensive or intermediate care unit (NICU, PICU, PCU). The house officer
      arranging the transfer needs to write transfer orders.

DISCONTINUING MEDICATIONS FOR SURGERY:

All medication orders shall automatically be canceled whenever a patient goes to the
      O.R. After surgery, write a new order for each medication. "Resume all previous
      orders" or "Resume all pre-op orders" is not acceptable.

NPO ORDERS:

The term "NPO" shall be interpreted to include medications unless specifically noted.
      When the patient is to receive nothing by mouth except medications, write "NPO
      except meds."

“ON HOLD" ORDERS:

Orders that are placed "on hold" must also include a date to resume, or the order will be
     discontinued by the Pharmacy.

FLUID RESTRICTED PATIENTS:

When a patient is fluid restricted, you may write an order "To Pharmacy: Minimum Dilution
    Protocol." The pharmacist shall calculate the minimum amount of fluid to dilute each
    medication and provide instructions for the nurse.

PATIENT'S OWN MEDICATIONS:

You must write an order to authorize the use of a patient's own medication in the
     hospital. This practice is discouraged because distribution of medications from the
     Hospital's Pharmacy provides the patient with the benefits of the unit dose system.

When someone other than the nurse is to administer the medication, an order must be
    written to that effect, e.g., "Mother may administer insulin."

When the patient or parent is to keep the supply of medication, an order must be written to
    that effect, e.g., "Keep meds at bedside."

DOSE STANDARDIZATION:

You are encouraged to order doses of certain drugs at predetermined dosage quantities.
     This standardization reduces waste by eliminating dosages, which may not be
     ordered for another patient. The Neonatal and Pediatric Intensive Care Units and


                                           25
      Intermediate Care Units are exempt from dose standardization. A list of
      dose/standardized drugs is in the Drug Formulary and Information.

MEDICATION RENEWAL:

All medications must be renewed or discontinued every seven days. Medication Renewal
      Forms will be placed in the patients' charts. The form lists all medications that will
      expire within the next 48 hours for that patient. You must review and reorder or
      discontinue the medications.

STANDARD ADMINISTRATION TIMES:

Standard administration times are established for the purpose of consistency and
     uniformity. For example, q.i.d. = 0900, 1300, 1700, 2100. A physician may override
     standard administration definitions, but to do so, must specify on the order the
     frequency and the times of administration.

DISCHARGE MEDICATIONS/OUTPATIENT PRESCRIPTIONS:

Discharge medication* orders should be written as soon before discharge as possible.

      *The phrase "Discharge medications" shall be used and not "DC meds." "DC meds"
      may result in the patient's current medications being discontinued earlier than
      intended.

Only licensed physicians and dentists (including interns and residents) having signature
       cards on file in the Pharmacy Department may sign or countersign prescriptions.

When writing outpatient prescriptions, use a separate prescription blank for each
    prescription.

Each prescription is valid for the number of refills indicated or one year from the date of
     issue, whichever comes first.

A list of "Medications Difficult to Obtain in the Community" is posted in each of the nursing
       areas. If a medication is on the list, you may want to inform the parent or guardian
       and suggest that the prescription be filled at the Hospital's Clinical Care Center
       Pharmacy.

For a patient to obtain over-the-counter medications at the Ambulatory Care Pharmacy, a
      prescription is required.

PRESCRIPTIONS INCLUDING CONTROLLED SUBSTANCES:

A resident’s DEA number should not be used as physician identifier except on prescriptions
      for controlled substances. The Texas Health and Safety Code precludes the use of
      the Drug Enforcement Administration number (DEA number) for any purpose other
      than validating the prescription of a controlled substance. The Code reads as follows:

         The director by rule shall prohibit a person in this state, including a person
         regulated by the Texas Department of Insurance under the Insurance Code or
         other insurance laws of this state, from using a practitioner’s Federal Drug

                                            26
           Enforcement Administration number for a purpose other than a purpose described
           by Federal Law or by this chapter.

      The Commissioner’s Bulletin, March 10, 1994, of the Texas Department of Insurance
      reads as follows:

             The purpose of this bulletin is to remind insurers and HMOs that it is not
             appropriate to require DEA numbers for reimbursement of prescribers.

      The Texas Medicaid Vendor Drug Program utilizes the physician’s state medical license
      number and not the DEA number as part of the claims process. The program has
      issued each teaching hospital a special number, which can be used in place of the
      Texas license number when a prescription is written by non-Texas license residents and
      interns. The number for Texas Children’s Hospital is TX018; the number for Baylor is
      TX039. If the resident has a Texas license, then that number should be used rather than
      the TCH or Baylor number.

      Non-licensed residents are not permitted to write prescriptions for controlled substances
      with one exception. The non-licensed resident can write for up to a seven day supply of
      a controlled substance upon discharge of a patient from the hospital. The prescription
      needs to be written on the special discharge prescription form. It cannot be written on
      any other form. When writing such a prescription, the non-licensed physician should use
      the Baylor DEA number – BT1325516.


   For all controlled substances, express the number of doses or quantity to be dispensed as
          digits and in script; for example, "Meperidine syrup 10mg/ml 30ml (thirty ml)."

Codes

      Red - Pediatric cardiopulmonary arrest: All pediatric house officers should respond
      immediately.

      Blue - Adult cardiopulmonary arrest: No response by pediatric house staff necessary.


CARLA -   DISASTER: THE CHIEF RESIDENT AND, OR, ACTING CHIEF
SHOULD REPORT TO THE EMERGENCY ROOM. ALL OTHER HOUSE OFFICERS
SHOULD REPORT TO THEIR REGULAR ASSIGNED AREAS AND AWAIT
FURTHER INSTRUCTIONS.


DR. PYRO - FIRE.

Coverage of Areas Without Assigned Pediatric House Staff

         Pediatric Coverage of St. Luke’s Labor and Delivery and Nurseries

      Upon request, an emergency response team attends emergencies in the St. Luke’s
      Labor and Delivery suite from the Neonatal Intensive Care Unit of Texas Children's


                                             27
Hospital. Participation in the activities of this team occurs during the pediatric resident's
Neonatal ICU rotation.

The Emergency Response Team from the Neonatal Intensive Care Unit at Texas
Children’s Hospital also covers emergencies that occur in the term nurseries at St.
Luke’s Hospital. In this case, an emergency is defined as:

A situation where the infant in the term nursery is displaying symptoms of distress and
immediate medical intervention is needed. Examples, which would be considered
emergent by the nurse, are:

       apnea
       seizures
       marked respiratory distress or depression
       bradycardia
       cyanosis
       hypoglycemia resistant to oral glucose
       shock or pallor

Any requests for emergency assistance in the St. Luke's Hospital Delivery Suites or
Newborn Nurseries should be referred to the Neonatal Intensive Care Unit at Texas
Children's Hospital, phone number 832-824-6155.

   House staff coverage of GCRC (TCH 10 ) non-research patients

       1.      The fellow or other individual responsible for the patient will not routinely
               check out the patient with the acting chief resident, but will do so only if
               he/she anticipates specific problems.

       2.      The nurses in the CNRC will call the fellow or other appropriate individual
               covering the service to which the patient has been admitted for any
               problems. If that individual feels that the problem cannot be handled over
               the phone without a physician seeing or examining the patient, he or she
               will page the acting chief resident to assess the patient. After the acting
               chief resident has seen the patient, he or she will institute appropriate
               management or contact the fellow. If the patient's condition is such as to
               require a great deal of physician time or constant physician attention, the
               fellow or other representative from the admitting service will need to come
               to the unit.

       3.      If the acting chief resident is unable to get to the CNRC in a timely
               manner, he or she may elect to ask an intern to evaluate the patient.
               Hopefully, this would be avoided in the early part of the academic year.

       4.      When the hospital is extremely crowded, it is sometimes necessary to use
               the CNRC for extra bed space. This unit should be utilized early in the
               evening with patients who are already in the hospital and are stable, and
               only after approval from the admitting physician. Under these specific
               conditions, the house staff from the transferring floor will continue to
               follow the patient.



                                         28
Martin I. Lorin House Staff Lounge and Call Rooms

      The Martin I. Lorin House Staff Lounge is located in the West Tower, 21st floor. Access
      is via proximity card reader. All categorical pediatric and medicine-pediatric residents
      have access. There is an on-call room for the house officer on call in the PICU, NICU
      and PCU and on TCH 9, 10, 12, 14 and 15. The call rooms for the acting chief, family
      medicine residents, and students doing subinternships is located on the 4th floor of the
      St. Luke’s Tower.

Conferences

      Monthly schedules of noon conference topics may be obtained in the Residency office or
      on the Residency Web page.

Pagers

      You can get replacement batteries in the House Staff office during regular hours (7:30
      a.m.-4:45 p.m.). You can exchange a malfunctioning or broken pager in the Hospital
      Information Services Department (HIS) in the Clinical Care Center, Suite 600.

      If you have not received a call for an unusually long time, call the page operator at
      X42099 to find out if you have had any calls, or to test your pager. Your pager can only
      be tested by the HIS Department. Please be protective of your paging unit. Each unit
      costs $245. If you lose your pager, you will be required to pay $100 towards the cost of
      replacement. Range is Intercontinental Airport to the north, Clear Lake area to the
      south, and Richmond to the west.

Long Distance Calls

      Occasionally, the situation arises where the house officer needs to make a toll call to the
      parents of a patient in the hospital (for example, if the patient suddenly deteriorates, etc.)
      or to another physician involved in the care of that patient.

      To make such a call, after approval by the chief or acting chief resident, dial the operator
      and tell him or her the person and telephone number to be called, the patient (including
      medical record and room number) for whom the call is required, the name of the house
      officer making the call, and indicate that the call has been approved by the pediatric
      chief resident or acting chief.

Photocopy

      Photocopying is available to the house staff in the Physicians Resource Center, A-180.

Laundry

      Lab coats are laundered free of charge at Texas Children's Hospital. Pick up and drop
      off is located in the resident’s lounge on the 21st floor of the West Tower. Lab coats will
      be picked up by the laundry service, cleaned and returned to the same area. You must
      have your name printed legibly on a label or embroidered on the lab coat. Coats
      will be collected, processed and returned in batches, not sorted by individual residents.
      This service is charged to the Department of Pediatrics and is for pediatric house officers
      only.
                                               29
Identification Badges

        The Graduate Medical Education Office at Baylor will furnish a laminated identification
        card. This is to be worn at all times while working in the hospital. There is a fee of
        $10.00 for re-issuing lost badges. A TCH I.D. badge, required for a discount in the
        TCH/St. Luke's cafeteria, may be obtained through the TCH security office, on the
        ground level floor by the gray elevator.

Meals

   Lunch is provided at most TCH noon conferences free of charge.

         A 20 percent discount is available in the TCH/St. Luke's cafeteria upon presentation of
         a valid TCH identification card. The Baylor I.D. is not adequate for the discount.

   ON CALL MEALS-TEXAS CHILDREN'S HOSPITAL.

         At the beginning of each rotation, each house officer will receive tickets for breakfast
         and dinner for each day of call for which he or she is scheduled. These tickets can be
         used at the cafeteria, McDonald’s or the CCC food court on any day during that
         calendar month. Therefore if you switch call with another resident you do not need to
         switch your meal tickets, unless the call extends into the next month.

         Please note that this means that you need to bring your call tickets to McDonald’s, the
         cafeteria, or the food court with you. If you do not have your ticket, you will need to
         pay for your meal. Under these circumstances you can get a receipt and if you turn in
         your receipt and meal ticket we will reimburse you for the price of the meal (up to the
         limit of the ticket, of course).

         If you miss a call because of illness, etc., you must either give your ticket(s) to the
         person taking your call or turn it in to Sherry. If you are pulled from an elective for call,
         please get the meal ticket(s) from the person you are covering for or from Sherry. On
         call residents at Texas Children's Hospital are eligible for dinner or breakfast or both,
         depending upon the call shift.

         The following residents are eligible for on call meals.


                                              dinner                  breakfast
                                           evening of call         morning after call
                Interns on
                9,10,12,14                        Y                        Y
                Intern or resident
                PCU                               Y                        Y
                Infant Care                       Y                        Y
                Acting Chief                      Y                        Y
                Resident
                Neo ICU                           Y                        Y

                                                 30
                Pedi ICU                          Y                       Y
                15 Tower                          Y                       Y
                ER
                Day, 8a-8p                        Y                      N
                Night, 8p-8a                      Y                      Y

                Short:
                M-F 6p-12MN                       Y                      N
                SS noon-MN                        Y                      N


Medical Students

       Core medical students rotate on the TCH wards. They should be assigned patients by
       the senior resident, and should be encouraged to actively participate in patient care.
       Work-ups are to be reviewed and discussed with each student by the senior resident or
       attending. The Office of House Staff Education, A-170, is not a lounge, restaurant or
       coffee bar for students. Please do not invite the students to the office for coffee.

       Sub-interns (senior students) may be assigned to any TCH floor. They will take call,
       averaging every fourth night, in conjunction with an intern, and their call schedule should
       be adjusted so that they are not always on call with the same intern. They will admit,
       work-up and follow patients as assigned by the resident. All entries in the chart -- orders,
       admission notes, and progress notes, must be reviewed and countersigned by a house
       officer.

Parking TCH EC at Night

       Some shifts for residents working in the Texas Children's Hospital Emergency Center
       starts or end at midnight. We have made arrangements so that individuals assigned to
       these shifts in the EC may move their car to the parking area opposite the EC on those
       nights that they arrive or leave around midnight.

       Note, this system is only for shifts starting or ending at midnight; it is not designed for the
       7:00 p.m. to 7:00 a.m. shift, etc. It is important that others not attempt to use this area
       as this might result in someone assigned to the 6:00 p.m. to midnight shift not being able
       to get in.

       BEN TAUB GENERAL HOSPITAL POLICIES/PROCEDURES

The Harris County Hospital District requires a photo identification badge, which can be obtained
in the security office, room 1ST13010. Phone number 713-873-2500.

5E - "The Floor"

    Hospitalization of a child is a very stressful situation for parents. Even when the admission
    seems routine to us, it is not to the parents. A few minutes devoted to the "care and
    feeding" of parents will make your life easier in the long run. Introduce yourself to the
    parents and explain your role to them, including a brief statement that there will be other
    physicians involved in the care of their child.

                                                 31
   The floor is staffed by four teams each consisting of a senior resident, one or two pediatric
   interns, rotating residents, and medical students. The ICU nurses and floor nurses each
   require a set of transfer orders when a child is transferred to them. Children up through 17
   years of age are admitted to 5 E. Ten isolation rooms are available for presumed infectious
   gastrointestinal or respiratory disorders, and others at the discretion of the chief resident.

   Patients under two years of age are admitted to Pediatrics whether their problem is medical
   or surgical. Patients over two who are admitted to a surgical service should be examined by
   the senior resident on call, should have IV orders and drug dosages checked, and should
   be followed peripherally by the team on call when that patient was admitted. Admission
   history and physical, daily progress notes, IV's and blood drawing are not the responsibility
   of the pediatric house staff on these patients. However, all bone and joint infections should
   be medical admissions with Orthopedics consulting instead of the other way around.
   Pediatric subspecialty consults on surgical patients are to be done through consulting the
   team that was on call the night that the patient was admitted.

   Patients in for two calendar days or less do not need a dictated discharge summary.
   Dictated discharge summaries are required on patients in for more than two calendar days
   and must be done the day of discharge. A handwritten final note as well as completion and
   signature on the front sheet of the chart is required of all discharges.

Pediatric Intensive Care Unit

   The care of critically ill children in Pedi ICU at Ben Taub is probably the most challenging
   and, potentially, the most rewarding experience available for house officers in the Baylor
   pediatric residency program. The presence of life-threatening situations coupled with
   chronic shortages of nurses and supporting personnel requires meticulous application of
   sound medical principles and attention to detail in all aspects of patient care. The following
   guidelines are suggested as an aid to patient management and house staff education.

   1. Orders should be written in concise language and shown to the nurse taking care of that
         particular patient before putting the chart in the "orders" box. Patients' weight and
         body surface area should be included on the order sheet. Notation of drug dose or
         IV note in mg/kg or cc/m2 should always be included.

   2. All patients must have lab flow sheets kept current on the bedside chart.

   3. Patients' body surface and weight in kilograms should be written on the lab flow sheet at
         admission. Each patient should also have a "code sheet" completed, outlining the
         drugs and their dosages used in resuscitation.

   4. Rounds can be more efficient if presentations are streamlined and somewhat uniform:

          a.   Name, day of hospitalization, diagnosis
          b.   Vital signs
          c.   Weight
          d.   Fluids (cc/m2) and cal/kg if indicated
          e.   Electrolytes
          f.   Current pulmonary status
          g.   Current cardiovascular status
          h.   Special problems

                                               32
          i.   Therapy and duration
          j.   Plan for day (or night), potential problems

   5. Notes on critically ill patients should be frequent and well organized. A systematic
         approach using the ABCD mnemonic is very helpful.

   6. The chief resident should be notified of ALL ICU admissions (pending initial evaluation
         and lab data at the discretion of the on-call resident) and ALL emergency procedures
         (intubation, surgery, use of pressor agents, etc.). Medical subspecialty consults at
         night require chief resident approval.

          The care of sick children requires a team approach, but it is expected that the
          pediatric intern admitting a patient will take the initiative to be actively involved in the
          major decisions concerning that patient.

Intermediate Care Designation

   Some bed on 5E may be designated as “IMC” beds for the care of children in need of
   monitors and close observation. Children acutely ill with respiratory illnesses are best cared
   for under this designation. Detailed flow sheet notes and close observation is mandated by
   the acuity of the illnesses under treatment. Once the patient is stabilized, the care may be
   down-graded to general inpatient status.

Chart Care

   Every patient requires a full H & P by the admitting PL-I regardless of whether or not a
   student is assigned to the case. The H & P should include a problem list with brief
   differential diagnosis and a detailed plan ("see orders" is not acceptable as a plan). Every
   chart should include admission height, weight and FOC with percentiles listed and all vital
   signs including blood pressure noted. Every chart should contain a problem list, a
   cumulative lab flow sheet, a daily growth chart if indicated, as well as a daily progress note.
   Charts are subject to review at any time.

   The on-call team should round on all isolation patients frequently during the night to prevent
   unexpected problems. Gowns should be worn in all isolation rooms and changed between
   patients with good hand washing between all patients isolated or not.

Normal Newborn Follow-Up Clinic

   To provide the pediatric resident with the experience of medical follow-up of the normal
   newborn infant after hospital discharge. Each pediatric level I physician will spend some
   time in the Normal Newborn Follow-up Clinic during their normal newborn rotation at Ben
   Taub. (The scheduling will be the responsibility of the Neonatology Chief Resident. The
   Chief Resident should ensure that the clinic assignments do not conflict with the resident’s
   Continuity Clinic assignment.)

   Each physician will see normal newborn infants after their early discharge from the hospital.
   These infants have been selected for their medical stability from the Birth
   Center/Postpartum Area. Adherence to the recommendations for follow-up from the AAP
   Guidelines will be followed.



                                                 33
   Each physician will work with the nurse clinician assigned to this clinic to ensure that all
   aspects of adequate medical follow-up are completed. Neonatal metabolic screening is
   performed prior to release from the Follow-up Clinic. Appropriate charting in the infant’s
   medical record will be carried out.

Pediatric Clinic

   Admission policies -- All admissions are to be cleared through the on-call resident on the
   ward. If there is disagreement about the need for admission, the resident in the ER has
   final say. When the ward resident is aware of an admission, the age, name, diagnosis and
   service should be written on the ward admission notebook, and the ICU or floor head nurse
   notified. On all admissions, procedures and labs (e.g., sepsis work-ups) are to be done in
   the clinic. When these are complete, please notify the ward resident again so that the intern
   or student can start his or her work (e.g., CSF cell counts) while awaiting admission of the
   patient. All patients should be taken to the floor as soon as possible, and patients admitted
   to the ICU must be escorted upstairs by the clinic resident. Gram stains, peripheral blood
   smear, extra spinal fluid, and other samples obtained in the clinic must accompany the
   patient to the floor. ICU patients are X-rayed in the unit. Admission orders (attention to what
   has been done in clinic) are required on all admissions. Ward resident needs to review,
   revise, and co-sign these orders before nurses will implement these.

   No antibiotics are to be started in the Pedi Clinic on any patient to be admitted to the floor
   without the approval of the floor resident, except meningitis patients or patients with other
   life-threatening infections.

Laboratories

   Labs drawn by technicians are drawn once daily only on Monday through Friday. Most
   chemistries and hematology tests can be done. CBC's only will be done on Saturday.
   "Additional lab" requests may require signature by a staff member on the lab request (check
   with lab on those specimens). Good follow-up on lab specimens to be sent out is advised to
   make sure they are sent from Ben Taub and received at the proper laboratory. Although the
   computer is quite helpful in obtaining lab reports, the delay in reporting of positive
   microbiology reports to the computer makes it essential that each team has any up-to-date
   culture list which is checked daily in microbiology. This delay in all reports of lab or
   radiographic studies in reaching charts makes up-to-date lab flow charts and recording of
   results in progress notes essential.

X-Rays

   X-rays are done on the first floor and in the Emergency Room. Portable films done in the
   ICU are double loaded and copies to keep in the ICU are available. House officers are
   responsible for obtaining these films and placing them in the ICU. The X-ray area is open
   7:00 a.m. to 11:30 p.m. on weekdays and 7:00 a.m. to 3:30 p.m. on weekends. On
   weeknights, portable X-rays are available for review. After 3:30 p.m. on weekends, all
   X-rays are done by the emergency center.

   Special procedures must be arranged some time in advance. This is usually facilitated by
   personally arranging it with one of the radiology residents. A radiology resident is on call in
   the hospital at night. One is encouraged to consult this source at night if help is needed.



                                                34
Battered Children

    A high index of suspicion should exist for this syndrome with unusual fractures or injuries.
    Emotional trauma can be a form of child abuse and requires appropriate evaluation and
    intervention. Possible battered children should not be worked up or followed by medical
    students, and medical students' names should not be on the chart. A drawing of all bruises,
    burns, etc. should be included in the chart. The CPS form must be completed by the intern
    and notarized. This includes pediatric consults done in the surgical ER. A notary is
    available 24 hours.

    A representative of the Harris County Children's Protective Service is available in the
    hospital for Child Welfare problems during the day at extension 43134. Social Service is
    expected to see battered children as well (extension 42547). Child Protective Services
    (main office 713-526-5701) should be called at night and on weekends.

    The Ben Taub Neonatology Handbook will be distributed on that rotation.

Daily Schedule on the Ben Taub Inpatient Ward

              Daily           0730-0830: PICU Rounds with Critical Care attending and chief
                                         resident.
                              0830-0930: Morning Report with the chief resident and Dr.
                                         Starke. Residents present all new admissions from
                                         the previous day.
                              1200-1300: Noon Lecture
                              1500-1600: ICU Rounds with the chief resident

              Weekends        0730-0830: PICU Rounds with the chief resident
                              0830-0930: Morning Report with the attending of the post-call
                                         team

                                         APPENDIX
PATIENT WRITE-UPS USING THE PROBLEM ORIENTED SYSTEM.

The physician often must deal with multiple problems in a given clinical situation and yet give
each the single-minded attention that is fundamental to developing and mobilizing his
enthusiasm and skill. This is possible only if he is able to organize the problems of each patient
in a way that enables him to deal with them systematically, and it is here that an organized
approach to the medical record (the patient's data base) can help.

We strongly recommend that all medical notes (initial work-up and progress notes) be written
according to the PROBLEM ORIENTED SYSTEM.


A PROBLEM IS DEFINED AS AN ABNORMAL MANIFESTATION (OR GROUP OF

MANIFESTATIONS), DESCRIBED AT THE HIGHEST LEVEL OF DIAGNOSTIC CERTAINTY

POSSIBLE AT THE TIME. A PROBLEM MAY BE A SIGN OR SYMPTOM, AN ABNORMAL

LABORATORY FINDING, OR A PHYSIOLOGIC DISTURBANCE OR A DISEASE, BUT IT IS
                                               35
ALWAYS A REASONABLE CERTAINTY. "RULE OUT PNEUMONIA," IS NOT AN

APPROPRIATE TITLE FOR A PROBLEM; "COUGH AND FEVER," IS A LEGITIMATE

HEADING FOR A PROBLEM. A PROBLEM LIST IS DIFFERENT THAN THE DIFFERENTIAL

DIAGNOSIS LIST.

For example, "R/O urinary tract infection" is not a legitimate problem heading. Either a urinary
tract infection clearly is present, or the findings which suggest that it is present should be stated,
e.g., specific findings in the urinalysis or a symptom such as dysuria or frequency. A logical
approach to the work-up of any of these findings can be defined. When the problem is stated as
"R/O urinary tract infection" the tendency is to do a urine culture, and if it is negative, to
conclude that the problem is solved, leaving the original complaint of fever, dysuria or
frequency, forgotten and unresolved.

Fragmentation of diagnostic entities by listing of several clearly related findings generally can be
avoided. There is no need to list cardiomegaly, edema, hepatomegaly, shortness of breath, and
rales as five separate problems. They clearly should be combined into one problem -- cardiac
failure. Rales would be listed separately only if you were uncertain that they represented failure
and were considering the possibility of pneumonia. However, if separate aspects of a single
disease will require distinctly separate diagnostic or therapeutic management, they should be
listed separately. For example, hemoptysis occurring in a patient with cystic fibrosis is a distinct
problem. The problem list, for this patient, would include 1) cystic fibrosis, and 2) hemoptysis,
even though the latter is clearly secondary to the first diagnosis.

On the initial admission note, each problem should be described at the highest level of
diagnostic certainty reasonable at the time. Following the delineation of each problem, list the
differential diagnosis. Comments as to the most probable diagnoses and "rule out" are
appropriate here, under the problem heading, not as a substitute for the problem heading.

ADMISSION NOTE

History and physical examination
Laboratory Data
Formulation
    list each problem
    discuss each problem, including differential diagnosis
Plan
    list by problem

PROGRESS NOTES

Date and time of day; number of days in hospital; number of days post-op or on specific
medication if applicable

Note should explain current situation rather than just stating most recent developments

Physical examination, laboratory data and other developments

Describe diagnostic and therapeutic plan for each problem


                                                 36
Each individual problem does not necessarily need to be discussed each day -- use judgment

The use of SOAP (Subjective, Objective, Assessment and Plan) is desirable, but not required.
It is less important than proper recognition, labeling, and organization of problems.

Each problem should be described at the highest level of diagnostic certainty possible at the
time. Tachypnea, rales and palpable liver are listed as such until the diagnosis of congestive
heart failure or bronchiolitis, etc. is established with reasonable certainty. Each problem may be
a diagnosis, a physiologic abnormality, a symptom or physical finding or an abnormal laboratory
value.

OFF SERVICE NOTES AND TRANSFER NOTES

These should contain a summary or synopsis of the patient's medical history, including hospital
course, and a description of the current pertinent findings on physical examination. A
chronological listing of major events and findings and a current problem list are invaluable. The
current plan of management, so far as it can be defined, should be outlined clearly.

ON SERVICE NOTES AND TRANSFER ACCEPTANCE NOTES

These should not be copies of the off service or transfer notes. There is no need to repeat the
patient's medical history. It is sufficient to indicate that the off service or transfer note has been
read, and the chart reviewed (if indeed this was done). The note should then provide a current
physical examination, assessment and plan.




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posted:7/26/2011
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