In-House and Same Day Surgery Patients
History and physical examinations: Done by the intern or the resident.
Discharge summaries: The resident is responsible for the timeliness and accuracy of the discharge summaries.
Discharge orders: The resident is responsible for ensuring that the discharge form is filled out accurately, and for discharging the patient. The resident shall notify the appropriate secretary of all post-discharge follow-ups via the EMR with all pertinent information.
Rounding: Urology residents round in the morning hours as a team on all inpatients and on all consults that have active issues. Every resident should know what is happening with every patient. A note will be written on all patients. A resident assigned to a specific attending will round with that attending in the afternoon. If you must leave prior to evening rounds, please let the attending to whom you are assigned know that you are leaving.
It is the attending's responsibility to sign out the patients to the attending on call. The resident on call should be familiar with all in-house patients and consults.
Consultations: In-house consultations are performed by the on-call resident. Ideally you should discuss the case with a senior resident and then the attending prior to finishing your note.
Emergency room consults go directly to the resident on call.
After consults have been seen, they should be discussed with the on-call faculty. Unless emergent, consults do not take precedence over clinic patients.
Telephone documentation: Outside telephone conversations with patients and other providers regarding patient management should be documented and incorporated into the medical record. All scripts should be entered under medications in the EMR.
ER consult or re-appointments following discharge (either Same Day Surgery or in-house): The responsible resident must communicate with the appropriate secretary what the followup appointment will be. Surgical forms, x-ray and laboratory requisitions must be completed. You must indicate the name of the attending backup.
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