Welcome to the Walter Reed Army Medical Center

The Medical Officer of the Day

MOD

As a resident this is one of your greatest challenges. You will be asked to perform a myriad of seemingly unrelated tasks, ranging from triaging patients to signing death certificates. The "usual" responsibilities include

admitting patients from clinics, the ER, air-evac and pre-admits
assigning an intern to each new admission
assigning medical students to appropriate cases
eyeballing each new admission for triage purposes
performing a complete history and physical exam on all admissions
appropriate documentation (see below)

Occasionally, you will be asked to

back-up your interns on cross-coverage problems
talk to patient families
or assist at codes

The MOD should try to refrain from getting involved in calls from outside hospitals, consults, or "bed-hunting". Although you may sometimes be called for these tasks, they should be referred to the Senior Resident on call.

There are a few key points to remember when on call:

it is important to ask appropriate questions of an admitting physician, but it is not appropriate to be obstructionist
it is in your best interest (and the patient’s best interest) to see all new admissions as soon as possible, although the relative time spent with each is a triage judgment by the resident
do not get bogged down in administrative detail--utilize the Senior and the Nursing Supervisor as needed
in-house back-up is the Senior, but use your Attending as a readily available source of second opinions
use the AOD for logistic concerns, e.g. unlocking call rooms, obtaining records, getting bodies removed from rooms
use the Nursing Supervisor to arrange for the expeditious cleaning of patient rooms

More specific issues are addressed in sections below.

MOD-Admissions

The MOD will receive calls on admissions from a variety of different sources. Staff and fellows from WRAMC clinics and the Emergency Room will contact the MOD directly to admit patients. Emergency room and General Medicine Clinic staff will contact the MOD about transfers from other facilities. The nursing supervisor/charge nurse will contact the MOD about airevac patients coming as in-patients.

A few years ago, based on a consensus opinion of the Retreat, we instituted a "cap" of ten admissions for the MOD. After this magic number, the MOD will "rollover" stable patients, and these will be dispositioned to the admitting teams the following day. The following are commonly asked questions:

What constitutes a "stable" patient?
The definition of stable is not the one that is used in ACLS classes. What is meant is that the MOD has seen the patient and has determined that the patient does not require acute medical care or intervention that night. By definition, then, this excludes most ER admissions and most clinic admissions (unless specifically approved by the Chief Resident) from being rollover candidates. Most of our rollovers are "elective" admissions that happen to arrive late via air-evac. It should be stressed, though, that criteria for rollover must still be met (e.g. no new fevers, stable BP, etc.)
What if the call team already has ten admissions and the ER has a patient to be admitted?
If one of the earlier admissions is not worked-up and is deemed to be a rollover candidate, then this could be done. If not, then this is one of the unfortunate circumstances where a team will exceed ten admissions.
Are weekends handled differently?
No
What needs to be documented in the chart on rollovers?
See below
What are bouncebacks?
A bounceback is the name ascribed to a patient who is readmitted after being previously discharged within a thirty day period. Our policy here is intern-specific, i.e., these kind of patients bounce back to the intern who cared for them during their most recent hospitalization, if that intern is still on the wards. The resident, therefore, is not vulnerable to bounceback except indirectly through the intern. If a bounceback comes in late in the day when the "target" intern is not admitting, common sense should rule the day and the patient should be taken care of by the call team (it may count as an admission) until the next day. Decisions to move the patient on to his or her old team will be decided by the residents on the following morning. However, if an intern is on the wards back to back, he/she will only admit bouncebacks within a thirty day period. Remember, the idea is to foster humaneness on the wards.
Do bouncebacks count as new admissions for "cap" purposes?
If your team gets one of your own bouncebacks on an admitting day, the following rule applies: if the patient has been out of the hospital for less than three days, it will not count towards admission quotas; however, if the patient has been out for more than 3 days (but less than 30), it will count as a new admission.
What about bouncebacks on non-admitting days?
If a bounceback is assigned early in the day to an otherwise non-admitting team, similar logic to that noted above applies. If the patient has been out less than three days, no credit will be given. If the patient has been out more than three days a ‘credit" will be given which will be used to count as an admission on the next admitting day.
What about patients returning from CVL?
In general, these patients go into the pool of daily admissions and are handled as such. The major exception is if the intern who placed the patient on CVL is still on the wards, in which case they are treated as bouncebacks and the rules noted above will apply. However, if the intern has back-to-back ward months, he/she will only admit the patient if it is within 30 days. Otherwise, it will go to the long call team.
What about transfers back to the wards from the intensive care unit?
Bounceback rules apply, i.e. the patient bounces back to the intern who admitted them. If the intern has rotated off the service, these patients are part of the daily admission pool.
Do residents always admit their own clinic patients?
No, unless it is either their admitting day, or they electively admit the patient (in which case they should try to coordinate it on an admitting day).
Do residents always admit their Attending’s outpatients?
The same logic as #10 applies here. Remember that some attendings admit a large number of patients, both electively and non-electively. It would, therefore, be unreasonable to expect their resident to handle all of these cases.
What about civilian emergencies?
By definition, we should not be caring for these patients on our General Medicine wards unless directed by Command. If these patients are stable enough for our wards, they are stable enough for transfer.
What about air-evac patients with outpatient designator (5A) who want to be inpatients?
Common sense and concern for the patient should be the prime concern here. Sometimes mitigating circumstances must be taken into account, e.g. patient financial status, level of acuity, level of ambulation, etc. If appropriate, these patients can be admitted to the Self Care Ward. In the case of the healthy active duty patient who is sent for a clinic follow-up and desires to be an outpatient, arrangements can be made for a barracks stay. (In any case, the MOD should not get involved in making these arrangements--let the AOD or admissions office take care of it.)
Who makes the final decisions on problem cases or exceptions to the policies noted above?
The Chief Resident--remember, this handbook cannot anticipate all possible scenarios and it is important to assess some issues on an individual basis. At night, the MOD should use the Senior as a second opinion. If there are still questions, the Chief Resident should be notified. The most important concern should always, however, be for the patient.

MOD-Paperwork

This will briefly outline the general documentation which is required on the wards. Some of this is the responsibility of the intern

H & P

Every patient must have this on their chart within 24 hours of admission. This is to be written by the intern or subintern. The H&P is the responsibility of the admitting intern, but this may be negotiated in the case of patients that are rapidly transferred to unit settings. Occasionally, residents or staff will admit their outpatients and write the H&P. This is a reasonable practice under certain circumstances but is not a Departmental obligation.

RAN

This is a resident admission note which is required on charts of patients who stay beyond 48 hours. This must be on the chart within 48 hours of admission. Because of problems in the past, it is recommended that the resident leave a brief notation in the chart after the patient has been seen. Example: "Patient seen and examined; record reviewed, patient is clinically stable, RAN to follow". This type of note serves to alert any consultants or other physicians that you know the case, even though there is no official paperwork prepared.

The purpose of the RAN is not to reiterate the entire HPI and physical exam as noted in the intern H&P, although the exact style of the document is left up to the individual resident. The amount of this type of data in the RAN will also depend on the accuracy of the H&P data. If you agree with the H&P, it is reasonable to state this and go from there. If you agree with most of it but want to add findings or note discrepancies, it is reasonable to do this. It is hoped that the bulk of the RAN will be concerned with the assessment of the case (i.e., differential diagnosis, assimilation of data, etc.) and plans for evaluation and/or therapy. The length of the RAN is up to the individual resident, but in general, one should strive to impart their thoughts in a relatively concise manner. In fact, some cases may lend themselves to one paragraph documents.

Transfer Notes

This refers to both transfer notes and acceptance notes. These are the responsibility of the intern in general. Again, common sense should rule the day here. It should be clear to the reader that the author of the note has interviewed the patient, reviewed the record, and examined the patient completely. It is not necessary that the entire data base be restated, although this is left to the physician’s discretion. It is, however, important that the exam is completely documented and the patient’s medication list is accurate. When writing transfer notes it is important to keep in mind what is essential information to the doctor at the other end. It should be clear in the note what the transferring team’s management plan is for each problem. The team receiving the patient can then decide with their attending if they want to adjust the plans. The note should include an up-to-date medication list with doses (as stated earlier), allergies, vital signs with weight, exam, pertinent labs, and a notation of any pending studies or labs. Remember to provide the data that you would want to have.

Progress Notes

Again, largely an intern responsibility. The word progress should be stressed, since these notes should serve to update the reader to new developments in the case on a daily basis. The policy of the Department concerning the frequency of these is as follows: every day on active patients (most of our inpatients); every other day is reasonable on inactive patients (e.g., long-term placement problems without ongoing medical illness, etc.). It is also acceptable to write a one or two line entry in the chart of these types of patients. It is also suggested that residents consider periodic update entries into the charts of their more active or complicated inpatients. These notes are not required, but many feel that they serve to clarify important issues and address concerns which frequently are omitted from intern or student notes. These issues include DNR counseling, cancer disclosure, drug/ETOH histories, etc. Sometimes a simple statement in the chart from the resident such as "recent consultation notes reviewed--I agree with their impressions"--can alert other readers to the direction of management. It is crucial to remember, however, that the chart is not a forum for debate. Make sure you and your attending document that you have discussed the treatment plans with the patient and that the patient understands and agrees with your plans.

Off - Service Notes

As noted above, common sense should dictate the length and content of these notes. Off-service notes are required on all patients any time an intern is changing services. These should be kept brief. It is perfectly reasonable to refer the reader to a previous summary note or H&P, however, when this is done the exact date of this note and author of the note should be identified. At a minimum, the off-service note must include current medications, physicial exam, laboratories, and a clear outline of pending data/studies and plans/dispositions. Always try to give the next intern the information that you would need to assume the daily care of that patient. On-service notes can be very brief, especially if a complete off-service note is written. Again, it is redundant to reiterate everything in the off-service note. However, complete documentation of a physical exam is important.

MOD-Miscellaneous

Thursday Nurse-Physician meeting: The second Thursday of each rotation at 1030 hours the Chief Resident, ward residents, 7th floor nursing supervisor, and ward head nurses hold a brief (usually less than 30 minutes) meeting in the General Medicine conference room to discuss active ward issues. The basic purpose of this meeting is to keep a constant line of communication open with the nursing staff. This is a mandatory meeting for ward residents and has proven useful in anticipating and solving problems on the ward.

Every Tuesday after Morning Report is discharge planning rounds. The four medicine teams are assigned their specific times. The schedules are noted on each ward board. The purpose is to meet in a multidisciplinary fashion with social work, nursing, OT, PT, dietary, and oncology nursing to try and work out discharge plans on our inpatients. This is a mandatory meeting and it is a good opportunity to touch base with specific support services for your patients.

While the team resident is attending discharge planning, the interns should be doing Cardex rounds with each ward nursing team. The importance of this must be stressed by the resident. This is where the intern will review the current active orders on each of their patients. This affords them the opportunity to discontinue unnecessary orders (e.g. q4h vital signs on a stable patient, BG chemstix on a patient with normal glucose, etc.) and to confirm that their patients are receiving the appropriate medications and other orders.