Sign-out/Handoff Overview:
Sign-out is centralized on Epic, and consists of a capsule history, initial neurological exam, current neurological exam, vitals, current medications, results and plans of care. Templates for the floor and stroke services can be accessed via the smart phrases .floorsignout and .strokesignout. This system ensures that all information vital to patient care is legible and universally accessible from any computer in the medical center. It is the responsibility of the PGY-2 to keep the neurology service sign-out accurate and up-to-date. The PGY-3 and PGY-4 consult resident is responsible for the consult sign-out list. Any patient seen while on call or nightfloat, who is ultimately admitted, must be placed on a sign-out list, either the service list if admitted to neurology or the consult list if admitted to another service.
Sign-out/Handoff is also given verbally from the day team to the call resident, from the call resident to the nightfloat and from the nightfloat back to the day team. Every resident is responsible for giving a comprehensive sign-out on each of their patients to the incoming resident. Both the Epic signout document and the verbal handoff process are an opportunity to reflect on a patient's condition and their care, to ensure nothing has been missed, and for a resident to self-assess their own knowledge, understanding, and comfort level with their management of each patient. Anticipatory planning is key – think ahead about what your patients might need or what may transpire, and you can alert your colleague to this in advance. Handoffs will be peer-evaluated in New Innovations, and reviewed by the Program Director.
Sign-out Guidance:
The AHRQ recommends the "I-PASS" mnemonic, which the signout templates are based upon. I-Illness Severity: one word statement of acuity; stable, watcher, sick P-Patient Summary: the updated "one liner" of patient's diagnoses, workup & treatment to date A-Action List: to-do items for the covering shift S-Situational Awareness: close-ended directions for anticipated changes; "if X then Y" S-Synthesis by Receiver: Receiver should ask questions and repeat back plan of care
Sign out Techniques: Utilize the Epic .dot phrases for the floor and stroke service written sign outs. These .dot phrases should capture the most important information that should be conveyed to other providers assuming the care of your patients. Everyone should be physically present and mentally vigilant to the information, and as a receiver, provide active feedback by asking questions and repeating back key points.
Tips for effective sign out: - Tell the on call team if the patient will be leaving the floor for any testing. - Tell the on call team about Sick consults or those with urgent imaging to follow-up, as well as anyone pending disposition. - Do not ask the on call team to follow-up non-urgent test results or consult recommendations if it will not immediately change patient care. - Direct admissions, outside hospital transfers, and transfers from the NSICU or other services should be discussed along with specific plans for their immediate care upon arrival to 8W. - The written weekend sign out should have an added section that indicates specific to-dos for the weekend team and should focus on anticipatory guidance.
Weekend sign out and shifts: - Weekend sign out will typically take place on Friday afternoons, which will allow the teams not on call to leave on time and for sign out to be less likely to be interrupted. - PGY2s, PGY4s, rotators, and PAs to meet for sign out together. As the year progresses, PGY4s may meet separately. - PGY2s who will be on call Friday overnight, Saturday, and Sunday should be physically present for Friday afternoon sign out. If you absolutely cannot make it, let someone know so you can be teleconferenced in. - On weekends, you will generally have a PA and moonlighter with whom to split the patients. This may not be the case on holidays, in which case the overnight resident should write notes on one of the services. Please arrive by 6:30 on holidays to allow time for sign-out, chart checking, and pre-rounding. - Upon receiving sign out in the morning, you become the primary provider responsible for all neurology patients. Although you may not be on either service during the week, and although we have incredible PAs helping us, those patients do not have any other physician primarily caring for them in the hospital. It is your responsibility to know the cases thoroughly to ensure continuity of care and patient safety (with the assistance of your PGY4).
Discharge Summaries:
The discharge summary is the most important document produced during a patient's admission. It is used to communicate details of the patient's hospitalization, including diagnosis, work-up, and follow-up to the rest of the Mount Sinai community. Junior residents and PAs complete the discharge summaries on all of their patients. Patients should not be taken off of the provider's personal list until the discharge summary has been completed. If the patient is to be discharged over the weekend, the resident from the week should have the discharge summary mostly completed in advance so as to reduce workload for the weekend team. If the PGY-2 is not present at the time their patient is discharged (i.e., a weekend), they should ensure that the summary is completed when they return. When there is a team change, the outgoing team should pend discharge summaries up until the point of the service change. Occasionally, if a student or sub-I is serving as the “junior resident” for a patient under the supervision of the PGY-4, the student can generate/write the summary, but it is the PGY-4’s responsibility to edit, finalize, and sign it.
Once signed, the discharge summary is sent to the supervising attending to review and sign. Once signed, it becomes a permanent part of the medical record, and may be accessed months or years later by other residents and faculty. Completion and quality of discharge summaries are overseen by the attending of record and both the department and the hospital administration. Avoid putting anything in a discharge summary that you would not wish to be reviewed in such a way. If the attending feels that the discharge summary is inaccurate or insufficient, they will send it back to the resident to be revised. Doing it well the first time will save time in the long run! If a discharge summary is not completed, it can result in the attending being suspended. You may be contacted to complete a “delinquent” discharge summary; please complete these immediately to keep our faculty employed. PGY-4s are available to answer questions and assist juniors with discharge summaries at any time.
A comprehensive discharge summary should include the following items
A brief summary of why the patient presented to the hospital
Relevant neurological exam on admission
Admitting diagnosis and Discharge Diagnosis + etiology
A succinct but comprehensive summary of what happened to the patient while in the hospital including all tests and procedures, significant lab findings, all new medications, any changes in the patients symptoms or examination, any consultations with other services and their findings, and any adverse events
Discharge medications
Follow-up plan, including outpatient appointments and any follow-up testing required or medication changes that will occur after the patient leaves (eg. "to repeat MRI in one month" or "increase topiramate to 100 mg in one week if tolerated")
The following should be specifically avoided in discharge summaries
Bullet points or lists, except for medications
Day-by-day recounts of the hospitalization (eg., "spiked fever on Tuesday; UA pending") is appropriate for the signout, but this is absolutely not to be included in the discharge summary – it is a retrospective review, not a blow-by-blow account.
Any but the most common/universal abbreviations and acronyms (must be understandable to a non-neurology nurse, medical student, physical therapist or family care physician). For example, "PERRLA" is acceptable; "MAE" ("moving all extremities") is not.
Avoid using "unapproved" abbreviations - the ones that scroll across the screen of every computer in the hospital.
Scheduling post discharge clinic follow-up
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Stroke follow-up
Fellows clinic - email stroke fellows
Drs. Stein, Fara, Hao, Sheinhart - lola.poku@mssm.edu
Drs. Dhamoon and Tuhrim - katherine.garcia@mssm.edu
Dr. Ostojic - lilibel.perez@mssm.edu
Epilepsy Follow-up - e-mail attending and/or amanda.perez@mssm.edu
Email the following addresses for follow up appointments: Discharge.followups@mountsinai.org with the following information
MRN:
Name:
Insurance:
DOB:
Pt contact #:
Requestor contact name and number:
Dept & appt request time:
Reason/diagnosis:
Preferred MD (if relevant):
Anticipated d/c date: