internal medicine residency manual - bluefield regional medical center

Bluefield Regional Medical CenterInternal Medicine Manual

Prepared By

Document Owner(s) Project/Organization Role Signature

Christopher Durando, DO Program Director

Ronnie Martin, DO Director of Medical Education

Internal Medicine Residency Manual Version Control

Version Date Author Change Description

1 08/23/07 Dawn Stull New

2 10/1/07 Dawn Stull Updated – 1.3

3 6/13/08 Dawn Stull Reviewed/Revised – Updated 3.1

4 3/1/10 Dawn Stull Reviewed/Revised

Note The content of a manual does not constitute nor should it be construed as a promise of employment or as a contract between Bluefield Regional Medical Center – Internal Medicine Residency Program and any of its employees.

Bluefield Regional Medical Center – Internal Medicine Residency Program at its option, may change, delete, suspend, or discontinue parts or the policy in its entirety, at any time without prior notice.

Effective 3/1/10IM Residency ManualLast printed 3/2/2010 3:30:00 PM

Bluefield Regional Medical Center at its option, may change, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the resident’s responsibility to obtain the most current version of this manual. A current copy of this manual

is available in the BRMC Medical Education Department. Any changes in this manual shall apply to existing as well as future

residents.

Internal Medicine Residency Manual

TABLE OF CONTENTS

1 INTRODUCTION..................................................................................................................... 6

1.1 Welcome....................................................................................................................6

1.2 Changes in Policies....................................................................................................7

1.3 Orientation Schedule..................................................................................................7

1.4 Educational Purpose..................................................................................................7

1.5 General Goals and Objectives....................................................................................7

1.6 Expected Outcome...................................................................................................10

1.7 Appointment.............................................................................................................11

1.8 Advanced Placement................................................................................................11

1.9 Promotion Criteria.....................................................................................................12

1.10 Qualifications............................................................................................................16

1.11 Terms of Service......................................................................................................17

1.12 Status....................................................................................................................... 17

1.13 Educational Stipend..................................................................................................17

1.14 Time Away/Absences...............................................................................................17

1.15 Illness....................................................................................................................... 18

1.16 Unauthorized Absence.............................................................................................18

1.17 Revocation of Off-Duty Hours...................................................................................18

1.18 Internal Medicine Residency Training Program Director..........................................18

1.19 Internal Medicine Residency Training Supervisor.....................................................21

2 DIDACTIC PROGRAMS.......................................................................................................23

2.1 Meeting and Lecture Requirements..........................................................................23

2.2 Attendance Rosters..................................................................................................24

2.3 Didactic Evaluations.................................................................................................24

2.4 Journal Club.............................................................................................................24

2.5 Morbidity/Mortality....................................................................................................25

Effective 3/1/10 Version 4



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2.6 Morning Report/Case Presentations.........................................................................25

2.7 Harrison’s Club.........................................................................................................26

2.8 Board Review...........................................................................................................26

2.9 Internal Medicine and Regional Grand Rounds........................................................26

2.10 IM Lecture Series.....................................................................................................26

2.11 Tumor Board............................................................................................................27

2.12 EKG Conference......................................................................................................27

2.13 OMM Lecture............................................................................................................27

2.14 Admission Rounds....................................................................................................28

3 COMPORTMENT..................................................................................................................29

3.1 Work Load Limitations and Volume Caps on Services.............................................31

3.2 Duty Hours...............................................................................................................32

3.3 Call Responsibility....................................................................................................33

3.4 Education Training Schedule....................................................................................34

3.5 Procedures...............................................................................................................36

3.6 Moonlighting.............................................................................................................37

3.7 Chief Resident Job Description................................................................................37

3.8 Research Responsibility...........................................................................................38

3.9 Cognitive Skills and Knowledge................................................................................39

4 CONTINUITY CLINIC............................................................................................................41

4.1 Overview.................................................................................................................. 41

4.2 Teaching Objectives.................................................................................................41

4.3 Continuity Clinic Evaluation......................................................................................42

4.4 Clinic Didactics.........................................................................................................42

4.5 Charting.................................................................................................................... 43

4.6 Clinic “After Hours”...................................................................................................43

4.7 Procedures...............................................................................................................43




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4.8 Vacation/Time Off from Clinic...................................................................................43

5 FLOOR RESPONSIBILITY...................................................................................................44

5.1 Electives................................................................................................................... 44

5.2 Night Coverage.........................................................................................................44

5.3 Response to Floor Calls...........................................................................................44

5.4 Rounds.....................................................................................................................45

5.5 Admission.................................................................................................................45

5.6 Admission Orders.....................................................................................................46

6 LOGS.................................................................................................................................... 47

6.1 Important Points to Remember.................................................................................47

6.2 What to Log..............................................................................................................48

6.3 How to Log...............................................................................................................48

6.4 Policy Statement.......................................................................................................48

7 MEDICAL DOCUMENTATION.............................................................................................50

7.1 Patient Workups.......................................................................................................50

7.2 Emergency Patient Workup......................................................................................51

7.3 Medical Documentation............................................................................................51

7.4 Medical Records.......................................................................................................53

7.5 Routine Progress Notes...........................................................................................53

7.6 Admitting Note..........................................................................................................54

7.7 Interval Notes: Off/End-of-Service Notes..................................................................54

7.8 OMT Notes...............................................................................................................54

7.9 Discharge Summary.................................................................................................55

8 ACKNOWLEDGMENT..........................................................................................................56

9 APPENDICES....................................................................................................................... 57

9.1 Personal Information Sheet......................................................................................57

9.2 Time Log.................................................................................................................. 57




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9.3 Resident Continuity Patient Log...............................................................................57

9.4 Attending Evaluation of Resident Form....................................................................57

9.5 Resident Evaluation of Faculty Form........................................................................57

9.6 Time Away Request Form........................................................................................57

9.7 360° Evaluation Forms.............................................................................................57

9.8 IM Resident End-of-Year Checklist...........................................................................57

9.9 Employee Expense Reimbursement Form...............................................................57

9.10 Patient Evaluation of Resident..................................................................................57

9.11 OGME-1 resident Evaluation of Resident.................................................................57

9.12 Resident Exit Questionnaire.....................................................................................57




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1 INTRODUCTION

This document has been developed by the Internal Medicine Residency Program in order to familiarize residents with Bluefield Regional Medical Center and provide information about working conditions, key policies, procedures, and benefits affecting residency at Bluefield Regional Medical Center.

Residents have an obligation to the patient care program of the institution and to the effectiveness of the educational program to which they have been appointed. The primary purpose of the program is to advance the medical competency, knowledge and skills of the trainee with a goal of excellence in the graduates of the program.

The most important criterion for the performance of duty and evaluation of the resident is the performance of their patient care and educational functions in a professional manner.

Professionalism includes placing the needs of the patient central to all actions, knowledge of and the ability to apply up-to-date and scientifically valid knowledge and skills for the benefit of the patient, honesty in action, word and deed, integrity and adherence to ethical standards and practices, individual responsibility, timely response to obligations, adherence to policy and procedures of the program, respect for self and others, and compassion in your care of patients and interactions with colleagues and peers.

The proper discharge of the responsibilities of the resident, as a professional, requires their full time effort and attention while on duty. All Residents shall remain within the Hospital as required by their duty hours and patient care responsibilities and shall be immediately available if on call.

The Director of Medical Education (DME) and Program Director have the responsibility and authority at all times to assure the residents’ effectiveness in the programs.

As part of the Bluefield Regional Medical Center, the graduate medical education program is a component of a long established community hospital and shares it mission to integrate is educational program with the mission of the hospital to provide access to the highest quality medical care for the sick and injured, to advance knowledge regarding the cause, prevention and treatment of disease and disability, and to educate men and women in the healing professions.

1.1 Welcome

Welcome to Bluefield Regional Medical Center! We are happy to have you as a new member of our family!

The mission of Bluefield Regional Medical Center is:

Our Mission:

Bluefield Regional Medical Center exists to provide our community with caring, quality healthcare at home.

Our Vision:

BRMC is a financially viable, efficient and effective healthcare provider earning the trust and confidence of our community.




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BRMC is the first choice for healthcare services, providing an appropriate range of services, quality physicians and technology to meet the majority of the healthcare needs at home.

BRMC meets the expectation for healthcare excellence in our community, eliminating the need to leave home except for highly specialized care.

BRMC is the provider of choice for physicians and the employer of choice for healthcare workers.

BRMC is an important contributor to the quality of life in our community.

The mission of the Internal Medicine Residency Program is to provide residents with a comprehensive structured clinical and didactic education and procedural clinical education in both inpatient and outpatient settings that will enable them to meet the health care needs of the patients they serve and become skilled, knowledgeable, competent, proficient and professional osteopathic internists.

1.2 Changes in Policies

This manual supersedes all previous Internal Medicine Residency manuals and memos.

While every effort is made to keep the contents of this document current, Bluefield Regional Medical Center reserves the right to modify, suspend, or terminate any of the policies, procedures, and/or benefits described in the manual with or without prior notice to employees.

1.3 Orientation Schedule

All new residents are required to attend a New Resident Orientation prior to the start of residency training. Residents’ off-cycle will be scheduled to meet with individuals prior to their first rotation. New second and third year residents will meet with the program director prior to the start of the new academic year to review their goals and expectations for the upcoming year.

1.4 Educational Purpose

The general internal medicine rotation is structured to provide residents with the fundamental knowledge and essential principles requisite to the practice of internal medicine. The basic techniques of physical examination, the necessary skills for performing clinical procedures, and the capability to communicate clearly with patients, their families and other members of the health care team are stressed in this residency.

1.5 General Goals and Objectives

The specialty of internal medicine consists of the prevention, diagnosis and treatment of diseases with emphasis on internal organs of the body in the adolescent and adult patient. The major goal of the osteopathic internal medicine program is to achieve mastery of the following core competencies:

1. Osteopathic Philosophy and Osteopathic Manipulative Medicine




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a. Integrate osteopathic principles philosophy and practices into the diagnosis and management of patients, respecting the principles of structure and function and the body’s inherent ability for health.

b. Apply osteopathic manipulative principles and therapy to patient management.2. Medical Knowledge

a. Demonstrate competency in the understanding and application of clinical medicine as it relates to patient care.

i. Demonstrate a thorough knowledge of the complex differential diagnoses and treatment options of the internal medicine patient.

ii. Integrate the sciences applicable in internal medicine experiences scientific applications of internal medicine to clinical practice.

b. Understand and apply the foundations of behavioral medicine as it relates to internal medicine.

i. Demonstrate the understanding of and application of the principle of palliative care and end-of-life issues for the benefit of the patient. Demonstrate competency in the identification and address the socioeconomic, ethnic, religious, and cultural aspects of the patient and their environment while recognizing their effect on the patient’s illness, presentation and subsequent management.

3. Patient Carea. Demonstrate an ability to thoroughly evaluate, initiate and provide appropriate

treatment in a timely manner for patients who are critically ill.b. Demonstrate an ability to diagnose, thoroughly evaluate, develop and

implement a treatment plan, addressing both acute and long term needs of the patient and employing the principles of chronic disease management in both the ambulatory and hospital environment.

c. Demonstrate knowledge of guidelines and standards for health maintenance, disease prevention and health screenings and their application to diverse patient groups to promote health maintenance and disease prevention.

d. Demonstrate an ability to gather appropriate essential medical information from patient interviews, relevant medical records, examinations and testing.

e. Demonstrate excellent skills in the physical exam of the patient and the procedures required of a competent osteopathic family physician

4. Interpersonal and Communication Skill a. Demonstrate competency and skill in the interview of, and the education and

motivation of patients. b. Demonstrate excellent communication skills that demonstrate respect and

cultural competency, with patients, the public, other physicians and health care professionals, both verbally and through written or electronic communication.

c. Create well organized, clear, succinct yet thorough and legible medical records.d. Demonstrate an ability to interact with support staff in the hospital and

ambulatory settings in a professional, ethical, positive and effective manner.e. Be knowledgeable of and apply resources to aid communication with non-

English speaking patients, and with those having sensory deficits (verbal, visual, and auditory).

5. Interpersonal and Communication Skillsa. Exercise effective patient interview skills.b. Demonstrate appropriate verbal communication with clarity, sensitivity, and

respect.c. Create well organized, clear, succinct but thorough and legible medical records.




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d. Demonstrate an ability to interact with support staff in the hospital and ambulatory settings in a constructive, positive and effective manner.

e. Identify methods to communicate with non-English speaking patients, and with those having sensory deficits (verbal, visual, and auditory).

6. Professionalisma. Be knowledgeable of and promote the discipline of Internal Medicine in the

health care system and how it relates to the delivery of health care service, public health and the relationship it has with the public and other health care professionals.

b. Be knowledgeable of and demonstrate the principles of appropriate professional and ethical conduct and integrity in dealing with patients, the public, other physicians and health care professionals

i. Identify and avoid if possible personal and professional conflicts of interest surrounding personal and professional actions both business, personal and medical practices.

ii. Demonstrate medical decision making that is effective, cost efficient and respectfully utilizes the resources of the patient and the public and avoids conflicts of interest or actions for personal gain.

iii. Honor the concepts that are embedded in the Osteopathic Oath, demonstrating, among other concepts contained in the oath, an understanding of the implicit position of trust and authority which patients place the physician; recognize the ethical requirement to avoid exploitation of this trust either intentionally or unintentionally.

c. Be knowledgeable of and apply the principles of patient privacy and confidentially inherent in the osteopathic oath as well as recognized regulation and laws such as HIPPA.

d. Recognize the cultural diversity and differences among your patients, including but not limited to religion, race, religion, sexual orientation, ethnicity, or cultural background, how they affect the patient’s actions and outcome and address them properly.

e. Recognize and model the physician’s ethical responsibility to provide access to care, continuity of care, equality in the delivery of health care and the avoidance of discrimination for all individual and groups of patients and demonstrate a personal and profession absence of discrimination.

f. Develop a commitment to personal assessment, personal and professional continuous quality improvement and lifelong learning

g. Identify the role of internal medicine as it relates to other medical disciplines.h. Complete training in personal health information protection policies, and

recognize their application in daily medical practice.i. Recognize the need for continuous quality of care in all patient populations,

and demonstrate lack of discrimination.7. Practice-Based Learning and Improvement

a. Develop professional leadership and practice management skills.b. Evaluate the progress of the training of the resident by using continuous

assessment tools.i. Utilize systematic evaluation to include self study and assessment,

individual trainee assessment, and outcomes analysis.ii. Participate in quality improvement programs and assessment activities

in the hospital and ambulatory setting.c. Expose the resident to research methodology in internal medicine.




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d. Identify information technology applicable to the practice of medicine and research.

e. Demonstrate the ability to effectively utilize such technology.f. Develop teaching skills in the internal medicine resident.g. Promote the development of commitment to habits of lifelong learning and

scholarly pursuit in internal medicine.h. Prepare the resident to meet the eligibility requirements of the AOA to take the

certification examination administered by the American Osteopathic Board of Internal Medicine.

8. Systems-Based Practicea. Develop professional leadership and involvement to advance the health care of

the nation. b. Develop administrative and practice management skills, including business

management skills, knowledge of the requirements of billing, coding, and compliance, the knowledge of the application of patient registries such as the AOA CAP, quality measures, electronic health record systems, etc.

c. Develop in the resident the skills needed to practice effectively and efficiently within the multiple delivery systems present in the USA and world, from patient center private care models to manage care, integrated delivery systems and public health.

d. Develop and promote health policy that advances the health of the nation, including advocacy for quality patient centered health care and the role of primary care in the USA’s complex health care systems.

General Goals and Objectives

1.6 Expected Outcome

1. To produce outstanding clinicians in the field of general internal medicine.

2. To produce clinicians who are grounded in evidence based medicine. 3. To produce clinicians who are compassionate and embody what it means

to be an excellent osteopathic general internist.4. To view the patient in their entirety, mind, body and spirit. 5. To produce clinicians who are proficient in the AOA Core Competencies

and osteopathic principles and philosophy. 6. To have a program that is compliant with the AOA basic standards as well

as program specific standards.7. To create an environment that fosters research opportunities as well as

other scholarly pursuits.8. To train internists & prepare individuals for their career goals in either

hospital based or community centered medicine or fellowship training.

9. To train physicians to deliver compassionate, culturally competent, high quality patient care.

10. To encourage the resident physician to achieve academic and clinical excellence.

11. To develop responsible physicians who will provide the best possible care to all patients while being good stewards of available healthcare resources.




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1.7 Appointment

Appointments to the Internal Medicine Residency Program are made on the recommendation of the Osteopathic Medical Education Committee, the Program Director and the Director of Medical Education.

Bluefield Regional Medical Center is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin or handicapped persons who, with reasonable accommodation, and can perform the essential functions of the job.

Policies, Procedures and Processes are outlines in the: Osteopathic Graduate Medical Education House Staff Policy and Procedure Manual

Refer to the House Staff Manual, Section 2.

Appointment Top of the Document

1.8 Advanced Placement

The Internal Medicine Residency Training Program follows the guidelines for residents requesting advanced placement of the AOA. A request for advanced placement must be received from both the resident and the program director at the advanced placement institution. This request must include the program director’s assessment of the resident’s academic status/equivalency and the resident’s academic level in comparison to other residents at the training level if advanced placement were to occur. Determination of advanced placement within these guidelines shall be made by the Council on Education and Evaluation of the ACOI and reported to the COPT. These guidelines are as follows: (Reference AOA-Basic Standards for Residency Training in Internal Medicine).

1. Advanced placement from non-internal medicine fields: A maximum of one-month of credit may be awarded for each month of training in general internal medicine or its subspecialties taken under the direction of an internist or medical subspecialist in an AOA or ACGME approved program.

2. Advanced placement from ACGME approved internal medicine programs: A maximum of one (1) month of credit may be granted for each month of post graduate training satisfactorily completed in general or subspecialty internal medicine in an ACGME approved program as verified by the osteopathic program director.

3. Advanced placement from traditional osteopathic internship: One month of credit may be awarded for each month of training in internal medicine or a medical subspecialty taken under the supervision of an internist during an AOA rotating internship in an institution with an AOA or ACGME approved internal medicine residency. A maximum of six months credit may be granted under this provision.

4. A request for advanced placement must be received from both the resident and the program director at the advanced placement institution. This request must include the program director's assessment of the resident's academic status/equivalency and the resident's academic level in comparison to other residents at the training level if advanced placement were to occur. Determination of advanced placement within these guidelines shall be made by the Council on Education and Evaluation of the ACOI and reported to the COPT.


http://www.do-online.osteotech.org/pdf/sir_postdocimstds.pdf


http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Resident%20Manual.pdf



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Advanced Placement Top of the Document

1.9 Promotion Criteria

RESIDENT COMPETENCY AND EXPECTATIONS TO BE ACHIEVED DURING OGME TRAINING:

OGME-11. Patient Care:

1) Uses appropriate evaluation of the patient, the formulation of a diagnostic and treatment plan and appropriate prioritization.

2) Demonstrates appropriate clinical skills in physical examination and communication.3) Monitors and follows up patients appropriately.4) Demonstrates professionalism, caring and respectful behaviors with faculty, peers, other

health care professionals, patients and families.5) Gathers essential/accurate information via interviews and physical exams and reviews

other data.6) Provides services aimed at preventing or maintaining health.7) Works with all health care professionals to provide patient-focused care.8) Knows indications, contraindications, and risks of some invasive procedures.9) Competently and correctly performs some invasive procedures under direct supervision.

2. Medical Knowledge :1) Uses written and electronic reference and literature sources to learn about patients’

diseases.2) Demonstrates knowledge of basic and clinical sciences and their application to patient

care and management.3) Knowledgeable of the principles and practices of osteopathic medicine and able to apply

to patient care and management.4) Knowledgeable of the basic principles of preventative care, public health, health

maintenance, disease preventions and wellness promotion.5) Scores above the 50th percentile versus peers on in-service examination.6) Passes COMLEX III.

3. Practice-Based Learning Improvement :1) Understands his/her limitations of knowledge and skills.2) Seeks supervision, consultation and guidance when required.3) Self motivated and independently responsible to expand his/her pool of knowledge and

skill.4) Able to use printed and electronic resources to advance knowledge; i.e. journals, text-

books, practice guidelines, references such as “Up-to-Date” to enhance patient care.5) Is aware of patient registry functions such as AOA CAP, quality measurement and

improvement resources and their role in improving medical practice and patient outcomes.

6) Accepts feedback and evaluation and develops self-improvement plans based on strengths and weaknesses identified.

4. Interpersonal and Communication Skills :1) Communicates effectively with patients, the public, peers, physicians, and other allied

health professionals.2) Writes clear, concise, accurate, pertinent and organized notes.




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3) Timely in meeting all professional responsibilities for documentation, logs, evaluations, medical records, etc.

4) Uses effective listening, narrative and non-verbal skills to elicit and provide information.5) Works effectively as a member of the house staff with other physicians and residents

and as a productive member of the health care team.

5. Professionalism :1) Demonstrates high standards of professionalism, honesty, compassion and integrity

consistent with the standards established for an osteopathic physician.2) Demonstrates the ability to establish a physician-patient relationship and trust with

patients and staff.3) Demonstrates ethics and a lack of discrimination, along with cultural competency, in the

treatment of diverse patient populations.4) Demonstrates the ability to work effectively in a team environment, demonstrating

respect for all members of the team. 5) Be and remain free from substance abuse or actively and cooperatively participating in

an impaired physician program.6) Be responsive to the needs of patients and society which supersedes self-interest.

6. Systems-Based Practice :1) An advocate for the patient.2) Complies with the procedures and standards of the hospital for risk management, peer

review and privileges, quality improvement, etc.3) Actively participates in the QA/QI, peer review, and risk management processes.4) Assists patients in dealing with the health care system complexity of the hospital,

community and nation.5) Aware of the different systems of health care delivery, their role in providing access to

health care and promoting health for the patient.6) Aware of the requirement for operation of a medical practice, billing, coding,

compliance, etc.

OGME-21. Patient Care :

1) Becomes competent in all of the expectations of the OGME-1 year 1; and, 2) Able to form a more expansive and appropriate differential diagnosis, make appropriate

decisions to narrow the possibilities, implement a through, effective yet efficient diagnostic evaluation and treatment plan that respects the patient and the resources of the institution and the patient equally.

3) Expanded mastery of the physical diagnosis and examination skills required of a skilled clinician.

4) Expanded mastery of the communication skills required to obtain a precise, logical and efficient history of the patient’s complaint and correlate that with the underlying cause and pathology.

5) Correctly interprets results of diagnostic procedures and correlates them with treatment and management processes.

6) Expanded abilities in time management and prioritization, able to respond to and manage multiple patients and cases at the same time appropriately.

7) Becomes more patient centered in decision making, considering patient resources, cultural difference, and patient preferences when making medical decisions regarding evaluation and treatment.




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8) Gains competency if not mastery in a progressive number of diagnostic and treatment procedures required of the specialty.

9) Knows and be able to explain and justify to patients and physicians the indications, contraindications, complications, benefits’ and risks of an of all diagnostic and therapeutic procedures utilized for patients of the discipline.

2. Medical Knowledge :1) Becomes competent in all of the expectations established for the OGME-1 year ; and, 2) Aware of indications, contraindications and risks of commonly used medications and

procedures.3) Demonstrates knowledge of epidemiological and social-behavioral sciences and their

application to patient care.4) Expands the resident foundation of knowledge through study, review of medical

research and scholarly activity on the psychosocial, neuropsychological and biomedical basis behind disease and conditions common to the specialty and its patients and to learn to adopt their clinical applications to treat patient in an outcome proven, scientifically valid manner to maximize outcomes and health.

3. Practice-Based Learning Improvement :1) Becomes competent in all of the expectations of the OGME-1 year; and, 2) Applies the outcomes of patient care, patient registries, quality reviews, and practice

guidelines to improve medical care and patient outcomes.3) Undertakes self-evaluation, peer evaluation, continuous competency and lifelong

learning and can apply with insight and initiative.4) Applies personal knowledge and skills not only to the care of patients but to the

formation of policy, the education of the public, students and other health care professionals.

4. Interpersonal and Communication Skills :1) Becomes competent in all of the expectations of the of OGME-1 year; and, 2) Creates and sustains therapeutic and ethically sound relationships with patients and

families.3) Able to effectively provide education and counseling to patients, families and colleagues

regarding medical decisions, patient care, etc. in a manner that inspires confidence, foster compliance and understanding.

4) Able to discuss end-of-life care with patient/families and be a resource in their decision making process.

5) Works effectively as a either a leader or member of the health care team, demonstrating respect for all members and appropriately utilizing each member of the team.

5. Professionalism :1) Becomes competent in all of the expectation of the OGME-1 year; and, 2) Develops and refine leadership skills.3) Develops the skills to inspire and guide others.4) Demonstrates a life-long-commitment to self evaluation and improvement along with

on-going professional development.5) Demonstrates a commitment to service of the osteopathic profession, public policy and

the expansion of health care and quality for the public.6) Demonstrates commitment to ethical principles of the profession, including but not

limited to the provision or withholding of care, patient confidentiality, informed consent conflict of interest, and ethical business practices, etc.




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7) Demonstrates a commitment to cultural competency, sensitivity to different beliefs, values, cultures, gender, ages, preferences and disabilities.

8) Develops a commitment to continuous quality improvement, transparency in action, word and deed.

6. Systems-Based Practice :1) Becomes competent in all of the expectations OGME -1; and, 2) Applies knowledge of how to collaborate, cooperate and consult with other health care

providers to assess, coordinate and improve patient care.3) Be knowledgeable of all of the resource available to advance the social, economic or

health care needs of the patient.4) Uses systematic approaches to reduce errors and improving outcomes.5) Be able to apply the principles of public health, preventative medicine, wellness

promotion to the practice of medicine.6) Be able to apply the principles of various health care delivery systems to the practice of

medicine and the care of the patient i.e., patient centered medical home, intragated health systems, managed care, etc.

7) Participates in refining and developing systems of practice and health management and patient care for the physician’s patients.

OGME-3:1. Patient Care :

1) Demonstrates competency in all of the expectations of OGME years 1 and 2; and, 2) Demonstrates competency in performing all ACOI required procedures, with an

emphasis on the application of osteopathic principles and philosophy and OMM/OPP.3) Knows indications, contraindications and risks of all ACOI required invasive procedures.4) Spends time appropriate to the complexity of the problem.5) Meets all expectations for patient care and management in the community clinic as well

as the hospital, i.e. patient volume, ability to care for a wide diversity of patients, all charting, billing, coding and practice management skills, etc.

6) Demonstrates the clinical skills expected of a certified osteopathic internal medicine physician.

2. Medical Knowledge :1) Demonstrates competency in all of the requirements of the OGME-1 and 2 years; and, 2) Demonstrates a thorough knowledge of practice guidelines, preventative health

measure, recommendations for health screenings.3) Demonstrates knowledge of chronic disease management. 4) Scores above the 50th percentile on in-service examination versus peers.

3. Practice-Based Learning Improvement :1) Demonstrates competency in all of the requirements of the OGME-1 and 2 years; and, 2) Analyzes personal practice patterns systematically, and looks to improve.3) Compares personal practice patterns to larger populations.4) Locates, appraises and assimilates scientific literature appropriate to specialty.5) Applies knowledge of study design and statistics.

4. Interpersonal and Communication Skills :1) Demonstrates competency in all of the requirements of the OGME-1 and 2 years; and,2) Works effectively as a leader of the health care team.




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5. Professionalism :1) Demonstrates competency in all of the expectation of OGME-1 and 2 years; and, 2) Demonstrates the potential for success in meeting all of the professional and ethical

expectations of an osteopathic internal medicine physician and patient advocate.3) Meets all of the requirements for a “training complete” certificate from the program

director and DME.4) Maintains participation and establishes leadership in the AOA, ACOI, state and local

osteopathic organizations.

6. Systems-Based Practice :1) Demonstrates competency in all of the expectation of OGME-1 and 2 years; and, 2) Demonstrates ability to adapt to different system of health care delivery and medical

practice, adopt evolving standards of care and treatment guidelines and incorporate new knowledge and skills.

3) Demonstrates a commitment to patient-centered, holistic, resource sensitive, cost effective primary care.

4) Demonstrates an understanding of the role of the internist and primary care provider and how it merges into the health care delivery system.

5) Demonstrates knowledge of the expertise and role of other members of the health care team to provide patient access and care.

6) Demonstrates the ability to use medical quality, patient safety, comparative outcomes, etc. to foster patient care improvements.

7) Demonstrates knowledge of the role of public health and how it integrates with other health care delivery systems to affect patient health and wellness.

8) Demonstrates knowledge of types of medical practice and delivery systems.

Promotion Criteria Top of the Document

1.10 Qualifications

Policies, Procedures and Processes are outlines in the: Osteopathic Graduate Medicine Education House Staff Policy and Procedure Manual

(Reference AOA-Basic Standards for Residency Training in Internal Medicine)

All residents shall be graduates of an approved college of osteopathic medicine and shall make application on the forms provided by the NRMP for prospective candidates. Residents must be members of the American Osteopathic Association (AOA) and American College of Osteopathic Internists (ACOI), and maintain membership throughout residency.

The residency training program in internal medicine is thirty-six (36) months in duration. The training consists of: thirty-six (36) months of general internal medicine, the first twelve (12) months of which are in an AOA-approved specialty track internship in internal medicine taken in an institution in which an AOA-approved internal medicine residency exists and which meets the criteria for approval by the ACOI and the AOA. Prior to starting residency, all residents must pass COMLEX Step II. Residents must pass COMLEX Step III, prior to the start of their post-graduate year two.





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1.11 Terms of Service

Policies, Procedures and Processes are outlines in the: Osteopathic Graduate Medical Education House Staff Policy and Procedure Manual

Internal Medicine Residency training is thirty-six (36) months. The contract will be issued for a period of one year. The Program Director, Director of Medical Education and the Osteopathic Graduate Medical Education Committee will determine if continuation in the training program will be granted.

Under qualifying circumstances, residencies may be extended through the FMLA or other approved leaves of absences or program modification.

Residents are allotted 20 paid days off each year, additional time taken off during residency must be made up at the end of the contract year and prior to the next level of training.

Refer to Resident Manual for contract contents.

1.12 Status

You are an employee of the hospital. As a resident employee, you are responsible to the Board of Trustees through the Director of Medical Education. The hospital is liable for your acts.

Remember – “moonlighting” is prohibited during the OGME-1 year and is grounds for immediate termination. OGME-1 residents cannot have a license to practice medicine outside of the institution or while on a designated rotation approved by the Program Director and the Department of Medical Education. You are not covered by malpractice insurance unless you are on an approved rotation. Under no circumstances may any resident engage in moonlighting, i.e. employment outside of the hospital, without the written permission of the DME. Unauthorized moonlighting is grounds for immediate termination.

1.13 Educational Stipend

Each resident will be allocated a specific dollar amount as outlined in the letter of appointment to be used for educational expenses during each year of training. These dollars will not carrier over into the next academic year. Funds will be available July 1st of each academic year.

Policies, Procedures and Processes are outlined in the: Osteopathic Graduate Medical Education House Staff Policy and Procedure Manual

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1.14 Time Away/Absences

Policies, Procedures and Processes are outlined in the: Osteopathic Graduate Medical Education House Staff Policy and Procedure Manual

(Refer to the Residency Manual, Section 8 – Time-Off Benefits)





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The resident will not be permitted to leave the hospital premises other than during off-duty hours without the permission of the Program Director, Director or Administrative Director of Medical Education or Administration.

Residents are allocated twenty (20) days off for personal reasons during each academic year of training. Additional absences can result in extension of training.

1.15 Illness

If a resident is unable to report to duty due to illness, he/she is to notify the Program Director, Department of Medical Education, the attending physician that the resident is rotating with and the switchboard. The resident may be required to go to the Emergency Room for an examination. (Refer to the Residency Manual, Section 8)

1.16 Unauthorized Absence

An unauthorized absence from duty will result in disciplinary action. Any unauthorized absence of three or more consecutive business days will constitute a voluntary resignation from the program.

1.17 Revocation of Off-Duty Hours

In the case of delinquent medical records, or other incomplete work, the resident may be assigned extra call or suffer other disciplinary action by the Program Director, Director of Medical Education or the Osteopathic Medical Education Committee Chairman, pending the completion of work.

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1.18 Internal Medicine Residency Training Program Director

The Program Director must be qualified to manage and direct residents in a graduate medical education program within the residency training requirements of the American Osteopathic Association and applicable laws and regulations.

The Program Director is directly responsible for the overall program administration of the Internal Medicine Residency Program.

1) Qualifications : a. The Program Director will be licensed to practice medicine in the state in which the

training site is located;b. The Program Director will be certified in internal medicine by the American

Osteopathic Board of Internal Medicine;c. Due to the necessity for continuing interaction with osteopathic internal medicine

colleagues in order to keep abreast of developments within the specialty, the Program Director will be a member in good standing of the American College of Osteopathic Internists (ACOI);

d. The Program Director will be an active member of the ACOI and meet the continuing medical education requirements of the AOA and the ACOI;




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e. The Program Director will be an active member of the department of internal medicine, and be engaged in patient care;

f. The Program Director will demonstrate experience and/or interest in the field of medical education as well as administrative ability and sufficient expertise to implement educational programs;

g. The Program Director will meet the standards of the position as formulated in the Accreditation Document for Osteopathic Training Institutions (OPTI) and the Basic Documents for Postdoctoral Training Programs;

h. The Program Director will have practiced in internal medicine or a medical subspecialty for a minimum of three (3) years (not including time as a resident), prior to becoming a Program Director;

i. The Program Director will be educationally and attitudinally suited to conduct a training program.

2) Responsibilities : a. The appointment of the Program Director will be approved by the AOA, upon

recommendation by the ACOI Council on Education and Evaluation, following the submission of his/her curriculum vitae. Continued approval is contingent upon the program director’s compliance with the provisions of the Basic Standards and directives of the CEE;

b. The Program Director’s authority in directing the residency training program will be defined in the program documents of the institution;

c. The Program Director’s will have sufficient dedicated time to administer the training program and will be compensated;

d. The Program Director will be directly responsible to the Director of Medical Education to verify that each resident is meeting or exceeding the minimum standards of the program;

e. The Program Director will evaluate the program, the residents and the faculty as described in Standard VII-Evaluation;

f. The Program Director will arrange rotations necessary to meet the program goals and inform the base institution of these arrangements so that affiliation agreements can be made;

g. The Program Director will, in cooperation with the AOA Department of Education, prepare required materials for on-site program review. The ACOI/AOA Program Review Workbook will be completed and provided to the on-site reviewer in the agreed upon time period prior to the on-site review. Review materials that are not provided in a timely manner will result in the program being recommended for a one-year probationary status without the ability to recruit new residents;

h. The Program Director will provide the resident with all documents pertaining to the training program and will also provide to the resident the requirements for satisfactory completion of the program;

i. The Program Director will submit to the ACOI and the Director of Medical Education, annual reports for all residents, including internal medicine specialty track interns. Annual reports to the ACOI will be submitted on-line by July 31 of each calendar year. Final reports for residents who complete the program in months other than June will be submitted within 30 days of training completion. A copy of each resident’s annual schedule will be kept on file and available during the on-site review. The ACOI will not review any program director or resident annual report which is submitted after the deadline until the program or resident, respectively, pays a delinquency fee of $150 per overdue report per year of training;




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j. The Program Director will approve and arrange supervision of the resident’s preparation of required medical research;

k. The program will be represented each year at the annual ACOI Congress on Medical Education for resident Trainers;(1) The Program Director will represent the program at this meeting, but may

designate another trainer to attend. Attendance by the Program Director, however, will occur no less often than every other year and will also occur during the first year of appointment. It is recommended that any physician anticipating appointment to the position of Program Director of an internal medicine program will attend the Congress prior to assuming the position.

(2) Documented travel and their expenses related to (1) above, not to exceed $2,500 each residency training year, will be reimburse directly to the physician attending the event upon submission of a properly completed expense report.

l. The Program Director will notify the ACOI of a resident’s entry into the training program by submitting a resident list annually on a form furnished by the ACOI;

m. The Program Director will be responsible for coordinating all schedules, including lectures and educational sessions, allocating appropriate time for resident participation. The Program Director will provide a method to document resident attendance at these meetings;

n. The Program Director will schedule completion of the required Resident Patient Evaluation for all residents prior to the end of the second training year;

o. The Program Director will maintain an e-mail address and provide it to the ACOI;p. The Program Director will ensure that the program description as described in

Standard III.D is accurate, complete and updated annually;q. The Program Director will be required to comply with the following actions and

procedures of the Council on Educational and Evaluation (CEE): (a) to undergo a site visit in the required time period(b) to follow directives associated with an approval action(c) to supply the CEE with requested information

A Program Director who does not comply with these actions or procedures will be deemed unqualified to continue in the position. In order to maintain program approval, the CEE will require that the institution replace the director with a qualified physician who will institute those actions needed for full compliance with the CEE’s decisions;

r. The Program Director will have sole responsibility and authority for the educational content and conduct of the residency;

s. The Program Director will fully implement the basic standards for residency training in internal medicine;

t. The Program Director, in conjunction with the Director of Medical Education will provide the proper supervision and clinical teaching of all training assignments in the continuity of care clinic. Continuity of the faculty is to be encouraged;

u. The Program Director will assure the arrangement of affiliations and/or outside rotations necessary to meet the program objectives.

v. The Program Director will maintain the ratio of qualified FTE supervisors to the total number of residents in the program at a minimum of 1:4;

w. The Program Director will, in cooperation with the AOA Department of Education, prepare required materials for inspection in advance of each inspection, and be available for the scheduled review;

x. The Program Director will provide each resident with a resident manual, which will contain all documents pertaining to the training program as well as the requirements for the satisfactory completion of the program;




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y. The Program Director will verify that the resident demonstrates competency in meeting or exceeding the minimum standards for quality patient care utilizing the competency-based evaluation;

z. The Program Director will assure that he/she and the internal medicine faculty are qualified to perform and teach all the required procedures listed in the ACOI and AOA Basic Standards for Residency Training in Internal Medicine;

aa. The Program Director will assume leadership for the coordination of inspections as required by the AOA/ACOI.

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1.19 Internal Medicine Residency Training Supervisor

Qualifications:

Teaching Faculty will:

1. Be either AOA or ABIN certified or a candidate in the process of being certified;

2. Be recertified within the period specified by the certifying body;

3. Participate in faculty development training in accordance with OPTI requirements as described in the Program to Accredit Osteopathic Postdoctoral Training Institutions;

4. Make available sufficient non-clinical time to provide instruction to residents;

5. Participate in the academic educational programs such as formal lectures, case conferences, journal clubs, book clubs, and board review;

6. Teach the application of osteopathic principles and practice in internal medicine;

7. Provide at all times adequate supervision and back-up for all patient care provided by residents;

8. Supervision provided will be progressive and adjusted to the training level and performance of each individual residents;

9. Complete and review with the resident a performance evaluation at the end of each rotation

10. Will assist the program director in determining the progress of each resident and whether a resident can advance to the next training year;

11. Participate in an annual evaluation of program goals and curriculum;

12. Function in an ethical and professional manner;

13. Will report to the Director of Medical Education (DME) at Bluefield Regional Medical Center;

14. Is responsible for reviewing all resident notes and writing an attending note on all patients;

15. Will perform monthly chart reviews with the residents to ensure that the charts are in compliance with AOA and ACOI guidelines;

16. Will review resident charts to ensure that each chart has a current medicine list, problem list, yearly history and physical with osteopathic structural exam and documentation of OMT when performed;

17. Be licensed to practice medicine in the state in which the training site is located;

18. Be an active member in good standing in the Department of Internal Medicine;




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19. Supervise all procedures performed by residents;

20. Be present at the internal medicine clinic at all times when residents are seeing patients, i.e. when resident clinics are in session (if applicable);

21. Be responsible for clinical teaching during clinic sessions as well as at least one lecture per month to residents on selected internal medicine topics;

22. Maintain adequate economic records at the internal medicine practice training site;

23. Be willing to precept medical students, interns and residents on IM clinical rotations as IM preceptor’s schedule permits;

24. Complete all paperwork as dictated by the ACOI (annual reports, quarterly evaluations, etc.).

Internal Medicine Residency Training Supervisor

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2 DIDACTIC PROGRAMS

2.1 Meeting and Lecture Requirements

Residents are expected to attend 100% of meetings and lectures and required to attend a minimum of 80% of all meetings/lectures as directed by the program director, exclusive of any excused lectures, and participate in major committee meetings such as Tumor Committee, Mortality Review Committee and clinical pathologic conferences, in addition to participation in institution intern/student education programs.

An attendance record of 80% at all such programs is required for successful completion of the Internship/Residency program. Disciplinary action and/or additional training may be required if the resident is found delinquent. Attendance is a requirement of your employment. Failure to attend violates your contractual relationship with the Hospital.

All in-house Residents will attend the following didactic sessions listed below. Residents on out-of-house rotations will attend educational programming as their rotation schedule permits unless excused by Program Director. Residents on out-of-house rotations must then attend didactic sessions at host site and submit logs of educational activities.

Morning Report and Morning Lectures: Monday through Friday 7 a.m. Noon and Midday Lectures: Per Residency Training Requirements. Weekly Educational Conference: Thursday’s 12-5, CME Programs: Grand Rounds, Clinical Pathology Conference, Department Journal Club, On-service X-ray Conference, Tumor Conference, General Medical Staff Meetings and Department Meetings, and other meetings/lectures as deemed required by the Program Director and Director of Medical Education. Residents are expected to attend all Autopsies on their patients and at all other times possible (announced as special Pathology Conferences). Residents are also required to attend their assigned committee meetings such as, Quality Assurance, Pharmacy and Therapeutics, etc. The resident will receive this assignment during orientation or near the start of each academic year.

Failure to comply may result in incomplete credit for the training year and failure to receive a certificate. Residents with less than 80% attendance at lectures will not be allowed to do outside elective rotations and may not meet the requirements to advance to the next year of training and may face further disciplinary action.

Attendance will be recorded for the following lectures – all lectures will be held in the Classroom unless otherwise noted on the Lecture Schedule.

(a) Morning Report and Daily Case Based Education Presentation

(b) Noon Lecture Series Daily

(c) Thursday Educational Series (weekly)

(d) Tumor Boards (monthly)

(e) Grand Rounds (as scheduled)

(f) Harrison’s/Cecil’s Club (weekly)

(g) Board Review (weekly)

(h) Journal Club (monthly)




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(i) Clinical Pathology Conferences (as scheduled)

(j) M & M Conference (as scheduled)

(k) Monthly Meeting with DME

To be excused from required lectures the resident must leave a message for the Department of Medical Education.

If you have an emergency and cannot attend a lecture the resident must notify the Department of Medical Education by noon for missed morning lectures and by 4 p.m. for missed noon lectures.

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2.2 Attendance Rosters

Attendance rosters will be prepared for each meeting, conference, and lecture, etc., which the resident is required to attend. These are specifically designed for the residency training program. In order to document your training for the American Osteopathic Association, it is mandatory that these rosters be completed and personally signed by those residents who are in attendance.

2.3 Didactic Evaluations

Residents are required to complete an evaluation on programs listed under Policy 2.1 of this manual. These evaluations will be completed in the New Innovations database.

2.4 Journal Club

Journal Club is an integral element in any medical training center. It directs education to externs and residents as well as attending physicians and reviews current literature on specific medical problems. Journal Club is held monthly by the Department of Medical Education as well as in other hospital departments, and attendance is mandatory when the resident is on service.

The format consists of house staff members presenting interesting cases to their peers. Residents review articles from journals recently released the month preceding the review. These journals include JAMA and the New England Journal of Medicine. In addition, subspecialty journals may be reviewed by all IM residents and formally presented to the IM Director and invited subspecialty physicians. Each resident is assigned a journal to read that are pertinent to the IM program. This review is opened to all house staff. In this format, review articles are evaluated as well as original articles critiqued for their significance in information, their type of set up for research, the number of people evaluated, and how well their tables and graphs correlate to their conclusion. The article should be critiqued on its content, as well as how information was gathered and techniques involved. The case presented should be first discussed with the attending physician and, if possible, have the attending physician or active physician in the case be present at the Journal Club.

Attendance sheets are to be signed and completed with date, time, topic, and presenter’s name and then sent to the Department of Medical Education along with the completed evaluation forms.




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2.5 Morbidity/Mortality

M&M conference will be faculty lead chart reviews from cases provided by the UM/QM committee and conducted under peer review protocols with Risk Management and Utilization/Quality Management staff also in attendance.


2.6 Morning Report/Case Presentations

Case Presentations:1. Each resident will be required to present no less than four case presentations during the

OGME-1 year.2. The presenting resident, in consultation with a senior resident, should choose a topic at least

fourteen (14) days prior to the scheduled presentation.3. The topic should pertain to a recent case.4. The topic should reflect the OGME-1’s clinical exposure.5. The topic should be very narrow and precise.6. Upon choosing a topic, prior to proceeding with preparation, it should be reviewed and

accepted by the Director of Medical Education.7. Each accepted topic will then be given to the Medical Education Office for announcement

purposes at least five (5) days prior to the scheduled presentation.8. The presenting OGME-1 should have pertinent materials available on the day of the lecture

(projectors, x-rays, scans, etc.).9. A written bibliography is to be distributed at the lecture.10. It is encouraged, but not required, to have handouts including graphs, outlines and

diagrams.11. Each prepared topic should have been reviewed in the recent literature as available from a

search of the literature using, index Medicus, Pub Med or Medline.12. The case will present the clinical findings, diagnostic evaluation, treat as well as the

pathophysiological rational for the condition and the treatment of the patient.

Morning Report:Interns, residents and students coming on duty at 7:00 a.m. are to assemble in the designated meeting room for morning report at 7:00 a.m. daily. Residents are expected to be present. The OGME-1 resident coming off of night call will write the name of admissions (patient initials) on the dry erase board at the front of the classroom, and review pertinent symptoms with the interns coming on duty.

Scheduled educational session occurs at 7:30 a.m. daily. This will include presentations by residents, students and staff physicians on practical medical and surgical problems. After this, the OGME-1 residents and students should all go to their respective floors and make rounds on their patients, spending time as needed to evaluate changes or see new patients. Progress notes should be written on all of the assigned patients in preparation for teaching rounds with the trainers.




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2.7 Harrison’s Club

Residents meet with the program director or his/her designee to review a section in the Harrison’s Internal Medicine textbook. Each month a different section is chosen. Each week a different resident is assigned to review the highlights of this section and make up appropriate questions that cover the material in that section.


2.8 Board Review

During Board Review, mandatory attendance is expected, unless excused by the program director. Residents meet from 4-5 pm. on Wednesday with the faculty to review assigned sections from the Internal Medicine Board Review assignments. The focus is on “medical knowledge”. Sections are assigned for the year and residents are expected to read the section and complete the board style questions. The Board Review may also be used as self-study and supplemental reading on rotation. It is NOT a substitute for the senior resident's mandatory board review course, as required by the ACOI.

Attendance sheets are to be signed and completed with date, time, topic, and presenter’s name and then sent to the Department of Medical Education.

2.9 Internal Medicine and Regional Grand Rounds

Internal Medicine and Regional Grand Rounds are simulcast periodically via teleconference/closed circuit TV from VCOM. Topics vary annually but include local, regional and worldwide medical experts, who will discuss topics, review cases and share research results. Residents assigned to in-house rotations are required to attend.


2.10 IM Lecture Series

The IM Lecture series occurs on Friday mornings from 7-8 am. The focus is on “the physician as teacher”. Resident or faculty lecturers will review a medical topic with PowerPoint presentation. Topics are selected in advance from the required curriculum and approved by the program director. Alternate topics maybe assigned in discussion with the program director. Presenters will review the medical literature as related to their topic; major studies and scientific advances in treatment will also be presented as appropriate. Handouts and bibliography will be included. Residents will be evaluated on PowerPoint slides, time utilization, and Q/A sessions with the audience and public speaking in addition to review of medical literature, accuracy and completeness of presentation. Formal evaluations will be maintained by the resident as part of their portfolio and by the Medical Education Department.




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2.11 Tumor Board

Tumor Board occurs monthly with residents and faculty presenting and reviewing complex oncology cases. The residents will present the clinical case and faculty from BRMC and staff physicians will lead a multi-disciplinary discussion including review of literature, therapeutic options for treatment including medical, radiation and surgical oncology options.


2.12 EKG Conference

Held as a part of the weekly educational days and presented by faculty members, the conferences conduct a review of basic EKG reading skills with the house staff and medical students. Initial lectures will be basic EKG review and subsequent lectures will focus on arrhythmia recognition and treatment; Acute Coronary Syndromes, inclusive of myocardial infarction patterns, and treatment; bradycardias; tachycardias; interesting cases; ACLS review; and pacemaker/AICD guidelines and indications. Residents will additionally be quizzed during the presentations and audience participation is quite high. Formal testing and feedback on EKG reading will also occur as part of competency-based training.


2.13 OMM Lecture

Twice monthly, the Osteopathic Medical Education Department and Family Medicine Department will provide formal lecture and at least once a month hands-on laboratory sessions to review basic and advanced osteopathic principles and techniques. All Internal Medicine residents are required to attend unless excused by the Osteopathic Medical Education Department. Senior residents may also be assigned to serve as faculty for the purposes of review and skill advancement of the resident physicians in the application of OMM/OPP techniques. All IM residents will also attend regional OMM/OPP reviews as assigned by the program director in order to meet their OMM/OPP training requirements.

Attendance sheets are to be signed and completed with date, time, topic, and presenter’s name and then sent to the Department of Medical Education.




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2.14 Admission Rounds

Admission rounds are to advance the education, medical knowledge and competency of the house staff offices by informing them of current, interesting cases presenting to the Hospital on the floor, as well as problem cases. Included should be a brief case presentation, differential diagnosis, current work-up and future work-up with prognosis. Discussion should occur with these cases to have everyone learning from the case. At BRMC, these generally occur in concurrence with or immediately after morning report and morning educational session or may be scheduled independently.

The attending physician should be notified in advance when their case is to be presented so they may attend and contribute in the teaching.


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3 Comportment

Resident Training Philosophy, Resident Responsibilities, Obligations for In-Hospital Coverage and Service, Hours and Duties:

The philosophy of the program is that through a combination of supervised clinical education and experience, didactic presentations and independent responsibility the hospital will provide a quality education for the resident physician.

The resident is expected to demonstrate the highest possible level of professionalism and ethics at all time and in all settings.

The resident is expected to present themselves in a professional manner, including dress, demeanour, communication and actions.

The resident will be responsible for the routine daily care and outcome of his/her patients under the direction and supervision of the attending physician or faculty.

The resident will discuss with and obtain consent of with the attending physician any proposed changes in care before initiating them.

The resident will initiate any necessary emergency patient care and notify the attending of it.

The resident will see all patients that they are responsible for as soon as possible after admission (guidelines are; 1 hour for ICU patients and not greater than 12 hours for floor patients) for an evaluation and admission orders. .

Residents will see all admissions from E.R. in the E.D. department before they are taken to the floor for admission.

The resident will contact the attending physician to review orders on all new patients before they are initiated by nursing staff.

The resident will oversee the writing of an admitting progress note and ensure that the H & P is performed on the day of admission (not greater than 24 hours after arrival to the floor).

Residents are required to review the admit notes of all admissions to their service and discuss them with the interns and students. Residents will have a note written to supplement the admit note on all unit patients on IM service or co-managed by an IM physician with a plan or recommendations when on call.

Medicine residents are not responsible for pediatric patient care unless it is a “Code Blue”.

The resident will round on all patients assigned at a minimum of once a day in the morning to evaluate status, update treatment protocol and write daily progress notes (guideline: this should occur before teaching rounds daily).

The resident will review/evaluate all x-rays and diagnostic evaluations pertinent to his/her patient with a faculty member or physician from the Department of Radiology.

The resident will scrub on all surgical procedures and participate in all diagnostic or treatment procedures that are performed on his/her assigned patients when every possible to maintain continuity of care.

The resident will complete any assigned discharge summaries on his/her patients designated by the attending physician within 48 hours of dismissal from the hospital.

Every resident must report the status of his/her patients and sign out each in-patient on his/her service with the night resident at prior to leaving the hospital daily. This should occur during evening report.




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The resident should review the case findings, diagnostic and treatment recommendations personally with any consultant involved with his/her patients care after the consultation is completed.

The resident is responsible to develop and deepen his/her knowledge of the diagnosis, evaluation, treatment and pathophysiology of the medical or socio-economic conditions of his/her patients through directed reading and self-study and to utilize outcome based, scientifically valid approaches to their evaluation and treatment.

The resident should be prepared to present the scholarly support for their decision and actions at all times to their attending physician or faculty.

No evaluation or treatment should be ordered by the resident unless that can justify its utilization and demonstrate how it will affect the outcome of the patient.

The resident will be timely and available to make rounds with all attending physicians and assist in patient care at the time established by the attending physician or faculty member unless it conflicts with protected educational times established by the Program Director or DME.

Resident duty hours are generally from 0700 until 1900 hours daily Monday through Friday. If not involved in educational events or rounding with attending physicians, the resident will be available during these hours to carry out his/her clinical and administrative duties, have time for individual study and development of knowledge and skills and for patient care.

The resident must be proficient in doing performing basic medical procedures, including venipuncture, blood gases, catheter placement, placement of venous access lines, N.G. tubes etc. This proficiency is best achieved and maintained by performing them on a regular basis to maintain this proficiency, the resident must perform these functions on their patients and other hospitalized patients on a regular basis, weekly if not daily.

Each resident must fill out an evaluation of the service and faculty at the end of each rotation and this evaluation must be turned in to the Medical Education Department within 7 days of completing the rotation. Failure to do so may result in disciplinary action ranging from reprimand, additional night or weekend call, suspension from service, appearance before the Medical Education committee and action up to and including dismissal from the program.

Each resident is expected to assist his colleagues and peers with demands of patient care and medical service to ensure patient care is available in a timely and appropriate manner. Each resident is primarily responsible for the comprehensive management and care of all patients on his/her educational service, including any patient assigned to a medical student.

It is a requirement that all residents (male or female) have a female in physical presence with them when examining a female patient, no matter what age.

The resident on duty is to be immediately available to answer calls from the ED or ICU and in a timely manner from other departments, and provide required patient care services in a timely manner.

The resident may be called to evaluate or care for a family member/relative/friend of a deceased patient who is in distress after the demise of a hospital patient. They are not a patient of the hospital; therefore, after urgent stabilization the residents should refer that individual to the Emergency Room for definitive care if care is required.

Residents on in-hospital service are responsible to their respective service and attending physicians between 0700 until 1900 hours Monday through Friday.

Residents in an office setting rotation will be responsible for being in the office setting during the teaching attending’s office hours and hours such as the hospital care of the attending’s patient load may require.




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Residents are responsible for making sure orders are written and reviewed if written by an OGME-1 resident for patients admitted to their service during the day and while on night or weekend call for all patients admitted to their attending physician service or to the physician faculty of the hospital service to which they are assigned (ex. Hospitalist, FM, ICU, etc)

Residents are responsible for the workup, treatment and management of all patients on their assigned service. They are required to review the evaluation, orders, and admit notes of all admissions to their service and discuss them with the OGME-1s and students. Residents will have a note written to supplement the admit note on all patients on their service or co-managed by an IM/FM physician.

Residents are to round on their service patients daily, unless scheduled off, review the note written by interns/students supplement that note as indicated.

Residents when on an in-house rotation are to actively participate in morning report. Residents are to attend all educational sessions and CME events produced by the

department or program, unless urgent or emergent patient care demand prevent. Coverage of new residents by Jr./Sr. residents shall be for a period initially of 3 months. It is not the resident’s responsibility to obtain DNR’s on patients unless they are

admitting the patient or it is a new change of the family’s thinking or the patient’s wishes. The resident is not to discuss the DNR with families of patients that they are not acquainted with their progress. This is the responsibility of the attending physician.

The residents are to assume the role assigned by the attending physician when on service and notify the attending or any acute change in the patient’s condition.

First year residents are not to independently conduct consultations and initiate treatment on patients.

3.1 Work Load Limitations and Volume Caps on Services

OGME-1 residents are not to have more than eight (8) admits during any shift and not to have more than 12 patients on the teaching panel that they are responsible for.

OGME-2/3 residents are responsible to supervise the clinical actions, patient management and admissions of all OGME-1 residents. The upper division resident on the service will assign all new admissions to members of the team as they occur in an equitable manner up to the limits of their responsibilities. If the junior residents “cap out” in either daily admits or total patients on their panel, the supervising upper level resident is not required to handle more than 8 additional admits per shift or less if the daily admit or teaching service cap is reached.

Teaching service will be capped at 16 admits per shift and 30 patients on the teaching service for each team when there is any combination of three junior or senior residents on the team. The teaching service is capped at 24 patients if there is any combination of two junior or senior residents on the team and capped. The teaching service obligations will be capped at 12 patients if there is only one junior resident or 18 patients if there is only one senior resident on the team.

Any admits or patient loads above these levels will be the responsibility of the attending physician or hospitalist supervising the service.

Residents are to respond to all Codes within the hospital.




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3.2 Duty Hours

Residents on in-hospital rotations will be responsible for being on service Monday through Friday from 7:00 a.m. to 7:00 p.m. unless on call or block nights. Block night are from 7:00 PM until 7:00 AM the following morning. Residents in an office setting rotation will be responsible for being in the office setting during the teaching attending office hours.

Residents will not be on call more than once each three nights nor once each two weekend. In most incidences, call will be less than this maximum amount with the average being one night in 6 and one weekend in 5.

Weekend call hours begin at 0700 on Saturday morning and end at 0700 hours on Monday morning. Call may be distributed in either 12 or 24 hour blocks for weekend or holiday call based on case loan and the demands of the patients in the hospital.

BRMC is committed to meeting all of the institutional and program requirements of the American Osteopathic Association (AOA) to ensure that the learning objectives of its residency programs are not compromised by excessive reliance on residents to fulfill service obligations. Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Didactic and clinical education has priority in the allotment of residents’ time and energies. Duty hour assignments recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. The hospital and osteopathic graduate medical education programs are committed to compliance with resident work hour regulations and requirements and will not allow or permit resident to work more than 80 hours a week averaged over a four week period.

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

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

3. The resident shall not work in excess of 24 consecutive hours inclusive of morning and noon educational programs. Allowances for inpatient and outpatient continuity, transfer of care, educational debriefing and formal didactic activities may occur, but may not exceed an additional 6 hours. Residents may not assume responsibility for any new patients after working 24 hours.

4. If moonlighting is permitted, all moonlighting will be inclusive of the eighty (80) hour per week maximum work limit and must be reported to the program director and DME.

5. The resident shall have during alternate weeks, one 48-hour period off or at least one 24-hour period off each week free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities.

6. Upon conclusion of a 24-hour duty shift, and the following academic time, trainees shall have a minimum of 12 hours off before being required to be on duty again. Upon completing a lesser hour duty period, adequate time for rest and personal activity must be provided.

7. A 10-hour time period for rest and personal activities must be provided between all daily duty periods, and after in-house call.




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8. All off-duty time must be totally free from assignment to clinical or structured or required educational activity.

9. Rotations in which the resident is assigned to Emergency Department duty shall ensure that the resident work no longer than 12 hours shifts.

10. The resident and the hospital must always remember the patient care responsibility is not precluded by the work hour policy. In cases where a resident is engaged in patient responsibility which cannot be interrupted, additional coverage should be provided as soon as possible to relieve the resident involved.

11. The resident may not be assigned to a 24-hour call shift more often than every third night averaged over any consecutive four-week period.

The Osteopathic Graduate Medical Education Committee (OGME) is committed to assuring that residents are able to report concerns regarding duty hours without retribution. Residents may report issues by:

1. Scheduling an appointment with the Administrative Director of Medical Education. 2. Scheduling an appointment with the Director of Medical Education.3. Contacting the resident representative of the Medical Education Committee who will

supply a report to the MEC.

MONITORING OF DUTY HOURS: The Department of Medical Education requires residents to report daily activities on a monthly calendar through New Innovations. The calendar must be completed by the end of each rotation. Hours above 80 are reported to the Director of Medical Education who will investigate each occurrence.

Duty hours will be discussed at the OGME meeting at least quarterly.

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3.3 Call Responsibility

1) Call coverage is from 1900 until 0700 hours daily Monday through Saturday, weekend call is from 0700 hours on Saturday until 0700 hours on Monday and holiday call is from 1900 hours on the eve of an approved holiday until 0700 hours the morning after the holiday.

2) Residents are responsible for all admissions to covered services and patients of the OGME faculty, as well as care of in-house patients and evaluation, stabilization and treatment of any complications to patient that develop.

3) Residents will evaluate and write an admit note on all admissions they are responsible for while are on call, prepare a diagnostic and treatment plan and present to attending physician for implementation.

4) If a patient is admitted from the ED the emergency room physician will discuss the patient with the attending and again with the resident before the patient is transfer to the floor or critical care unit.

5) Residents are not to have call more frequently than once every three days. 6) Attending physician personally or through coverage arrangements is to be available for

consultation regarding the evaluation and treatment of their patients at all time for the on call resident.

7) On weekends the residents will evaluate all assigned patients under Family Medicine or Internal Medicine teaching service and conduct daily care under the supervision and at the direction of the respective attending.




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8) All patients on the teaching service in the ICU or CCU unit must be reviewed and be signed out to the evening resident.

9) It is the duty of the resident on call to evaluate all the patients in the unit or on the teaching service that have an acute change as soon as possible, develop an evaluation and treatment plan and notify the attending physician if warranted, and then detail their actions in a progress note.

10) If an acute situation occurs concerning a patient on the teaching service or an emergent situation occurs for any other hospital patient and the resident requires assistance, guidance or and supervision and the attending physician is unable to be reached, the resident should contact either the Program Director, the DME or the Chairperson for the appropriate medical department for assistance until the attending has responded.

11) No patient is to be admitted to the critical care unit without consent of the attending physician managing the patient in the unit.

12) Residents are not to be called to perform routine tasks or for orders for routine lab work, x-rays, or EKGs on patients when on call.

13) On any direct admit to the teaching service or critical care unit from other than the ED, orders are to be written by the attending or the attending is to call the resident with a history and preliminary diagnosis and the resident will write the orders.

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3.4 Education Training Schedule

Clinical education at Bluefield Regional Medical Center is provided during thirteen (13) four week blocks of instruction normally beginning on July 1st and ending on June 30th of the academic year.

All residents’ programs and curriculum are designed to meet the requirements of the AOA standards as well as the curriculum of each of the resident training program specialties provided at BRMC, provide the opportunity for the development of competency in the resident, promote excellence, life-long learning and advance quality medical practice and patient care and meet the patient care needs of the institution.

Internal Medicine residents have the following basic standards and requirements during their residency at this time (subject to change each July):

o 64 weeks of In-House Internal Medicineo 4 weeks of Emergency Medicine (min. of 16 shifts)o 8 weeks of ICU/CCUo 4 weeks of General Surgeryo 4 weeks of OB-GYN/Women’s Healtho 48 weeks of Medicine Sub-Specialtieso 20 weeks of electives

Training and experience in:o Community Medicineo Geriatricso Behavioral Medicineo Quality Assessment and Patient Safety Systemso Medical Delivery Systems and Practice Managemento Osteopathic Principles and Practices




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At BRMC, we require the following in addition to the basic standards:o 4 weeks of Critical Care

The following schedules have been designed to meet the requirements of the residency and advance the professional growth of the resident. Modifications can occur only with the consent of the program director and the DME.

Internal medicine OGME-1 residents: Four blocks of In-House Internal Medicine Two blocks of Internal Medicine Block Nights (IM) One Block of Cardiology One Block of Pulmonology One block of General Surgery One block of OB-GYN/Women’s Health One block of ICU/Critical Care One block of Emergency Medicine (16 shifts) One block of Electives

Internal medicine OGME-2 residents: Four blocks of In-House Internal Medicine Two block of Internal Medicine Block Nights Two blocks of Electives Four blocks of Medical Selects One block of ICU/CCU

Internal medicine OGME-3 residents: One block of Internal Medicine Block Nights Five blocks of Internal Medicine One Block of ICU/CCU Four Blocks of Medical Selectives’ Two block of Electives

Medical Selectives that must be taken during the three years of the residency include the following: GI, Cardio, Hem/Onc, Pulmonary, Neurology, Endocrine, Rheumatology, Nephrology, and Infectious Disease. Cardiology and Pulmonology are to be taken during the OGME-1 year by all residents.

The internal medicine resident may also take: dermatology, hepatology, anesthesia, critical care, etc. The resident may repeat any selective or required rotation if desired one time to fulfill the requirements of the selectives (ex: Two rotations in cardiology or pulmonology).

One block of research, if approved by the program director and DME, may also be taken and count toward selective time if other requirements are met.

Internal Medicine residents may take one block of elective time during the OGME-2 and OGME-3 year out of house consistent with the policy and procedures of BRMC.

One block of elective time may be taken for research if approved by the program director and DME.




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Internal Medicine residents will have one half day each week, at a minimum of 36 weeks of each year of attendance in the internal medicine continuity care clinics associated with the hospital as a concurrent requirement.

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3.5 Procedures

Residents are provided the opportunity to perform procedures as they arise. Residents are expected to become proficient in the following procedures:

1) Sufficient experience and training to ensure proficiency in the following procedures, including indications, contraindications, complications, limitations and interpretation:

a. Central venous line placementb. Arterial puncture for arterial blood gasesc. Osteopathic manipulative treatmentsd. Endotracheal intubation

2) Sufficient experience and training to ensure proficiency in the interpretation of the following procedures:

a. Arthrocentesisb. Paracentesis with ultra soundc. Thoracentesis with ultra soundd. Peripheral blood smearse. Exercise stress testsf. Holter monitorsg. Lumbar punctureh. Spirometryi. Sputum gram stainj. Urine microscopyk. Vaginal wet mounts

Formal lectures, hands-on labs and videotape procedure demonstrations are used to introduce the procedure and review anatomy and indications/contraindications of the procedure.

Residents will also develop procedural skills on selective and elective rotations; such as, sports medicine, geriatrics, urology, cardiology, pulmonary, nephrology, gastroenterology, radiology and hematology et al. under the direct supervision of the attending physicians. Additional skills in intubation and central lines are obtained, if needed, with the assistance of the anesthesiology department.

As mastery of skills is demonstrated during the residency training based on direct observation of the faculty and review of resident logs, the resident may be signed off as independent in the procedure and the medical staff office will be notified in writing.

All procedures are to be done under the supervision of an attending physician who is responsible for the care of that patient. This supervision can be direct or indirect, depending on the experience of the resident. Direct supervision is required for OGME-1 residents.

A resident is not to start any non-emergency procedure until the resident obtains permission from the responsible attending physician.

OGME-1 residents should have first opportunity to do procedures on patients assigned to their care.




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Informed consent must be obtained from the patient before any procedure is performed expect in an established emergency.

Procedure notes must be written immediately after the procedure and subsequently co-signed by the attending.

Procedure logs must be completed in New Innovations by the resident and signed by the supervising resident/attending. These will then be reviewed by Program Director or Department of Osteopathic Graduate Medical Education.

Each time a procedure log is reviewed, the program director will assign a privilege status. Guidelines are as follows:

Level I = Direct supervision only – OGME-1 Level II = Perform and teach with indirect supervision – OGME-2 Level III = Perform with indirect supervision; can teach and certify others – OGME-3

Residents unable to master the expected skill levels will be assigned additional procedures until such time that the procedure is mastered. Those residents at the OGME-3 level who have not documented competency in all required procedures will not be eligible for graduation.

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3.6 Moonlighting

All OGME-1 residents are expected to devote themselves entirely to the service of the Hospital and its training program. During their period of service they CANNOT participate in any outside activities of a professional nature accept educational, and then only with the permission the Director of Medical Education.

They shall not be permitted to participate in private, professional, or clinical practice wherein they or others collect compensation for an OGME-1 resident’s services. Moonlighting will be considered just cause for immediate termination of the OGME-1’s contract.

OGME-1 residents operate under a restricted training license that allows their practice of medicine only within the approved Training Program of Bluefield Regional Medical Center.

Residents may moonlight provided they have obtained a full, unrestricted medical license and DEA number and only with the expressed, written consent of their Program Director provided such activities do not interfere with their training obligations. House Officers who moonlight are responsible for their own medical malpractice insurance coverage while engaged in moonlighting activities and time moonlighting will be included on the Duty Hour log of the resident.

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3.7 Chief Resident Job Description

The Chief Resident for the Internal Medicine Residency Program will be nominated by the Program Director upon consultation and advice from the OGME Committee, Director of Medical Education and the Administrative DME (ADME). It contains both a leadership and administrative position meant to improve and facilitate the training programs for medical students, interns and residents at Bluefield Regional Medical Center.

Qualifications:1. Resident in good standing at Bluefield Regional Medical Center preferably in their senior

year of training.




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2. Demonstrates an interest and participation in the educational programs at Bluefield Regional Medical Center.

3. Demonstrates excellent rapport with peers.4. Approval for acceptance of the position of Chief Resident by the applicant’s Program

Director.5. Demonstrates and participates in scholarly activity, as well as possessing the work habits

appropriate and consistent with the mentoring responsibilities of the position.6. Willingness and ability to attend training and skill development courses or CME as suggested

by the DME/ADME to prepare and guide the applicant in performing their duties as Chief Resident.

Responsibilities: (Inclusive of but not limited to)1. Assists in the development of the resident rotation schedule.2. Is responsible for scheduling topics for IM lectures, journal club and board review.3. Assists in the development of and supervision of the resident on-call schedule.4. Acts as liaison between the Department of Medical Education and all house staff officers,

medical students and allied health students.5. Acts as liaison between house staff physicians and nursing staff.6. Attends all OGME Committee meetings.7. Must keep all logs and inpatient and outpatient charts current.8. Actively mentors the house staff, medical students and allied health students in the areas of

scholarly activity, professional/ethical behavior and work habits. The Chief Resident(s) is/are directly responsible to the Director of Medical Education (DME). In the absence of the DME, the Chief Resident is responsible to the Program Director, Administrative DME, the Chairperson of the OGME Committee, and the Vice President of Medical Affairs, in this order.

8. Introduces all guest lecturers/presenters at morning and noon lectures.9. Serves as member of Peer Review Committee, subcommittee of the OGME Committee as

needed.10. Assists with the development and procurement of resources to support medical education

activities at Bluefield Regional Medical Center.11. Attends House Staff meetings monthly.Compensation:

Chief Resident Stipend: $1,000 (reviewed annually)

Terms of appointment: July 1, 20__ through June 30, 20__Return to top

3.8 Research Responsibility

Residents may meet research requirement by demonstration and documentation (via Portfolio) of any three of the following:

1. Original research, accepted for publication by peer review journal – meets all requirements

2. Original Research, accepted and presented at Local, Regional or National Convention (poster presentation) – meets all requirements

3. Participation in Journal Club, inclusive of obtaining, assigning and presenting articles with written critique of articles submitted for review by program director twice annually. Resident




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participation in Journal Club will be review and evaluated twice annually by the program director

4. Participation in Review of Medical Literature Didactics, in conjunction with VCOM, offered twice annually

5. Participation in and submittal of written reports reviewing the medical literature for Peer Review Activities in compliance with policies and procedures of the QM/UR Committee, Critical Care Committee or Department of Internal Medicine

6. Participation in and submittal of written reports, inclusive of medical literature review, in conjunction with the Quality Improvement Initiatives of Bluefield Regional Medical Center.

7. Presentation of four (4) lectures annually inclusive of medical literature review and evaluation by member of IM Faculty of the presentation at either House Staff Formal Didactics, Local, Regional or National Conference, or Medical Staff/Departmental Meeting

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3.9 Cognitive Skills and Knowledge

At the completion of the training program, the graduate shall:

1. Accurately identify potential medical problems:a. Describe the medical problems presented and develop an

appropriate differential diagnosisb. Define information in the patient record which aids in said

descriptionc. Elicit and record appropriate history which defines the problemd. Perform an accurate physical examination to identify and confirm

the diagnosis2. Utilize and interpret laboratory and ancillary testing to define or discover

problems:a. Accurately diagnose problemsb. Describe potential etiologies for each presenting problemc. Identify signs and symptoms for each problemd. Prioritize findings with respect to potential etiologiese. Rank potential disorders by likelihood based on presence or

absence of findings3. Confirm the diagnosis of the problem:

a. Describe the diagnostic resources for each disorderb. Generate a diagnostic plan to appropriately confirm the disorderc. Perform diagnostic procedures where appropriated. Properly interpret results of testing, recognizing the relative

sensitivity and specificity of the testse. Understand cost effective diagnostic planning

4. Competently treat the problems:a. Define the needs and circumstances of the patientb. Describe the conventional and alternative therapies for each

problemc. Generate treatment plans which are cost effectived. Monitor response to initiated treatment, including appropriate

follow-up testing if needede. Determine efficacy of chosen treatment




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5. Communicate effectively:a. Use standard English effectively but be culturally competent to

communicate with the patient and their family or support system appropriately.

b. Use accepted medical terminology appropriatelyc. Develop listening skills for patient, family, and ancillary providersd. Effectively and sensitively respond to patient questions and fears

or concernse. Record data and plans clearly and completely in progress notes,

summary reports, history and physical reports, and procedure reports

f. Respond promptly to patient and family requests for information or explanation

g. Demonstrate reasonable facility in use of computer network information and record keeping systems

6. Demonstrate professionalism:a. Be characterized as competent, approachable, empathetic,

conscientious, and cooperativeb. Develop sensitive yet definitive leadership capabilities when

dealing with house staff, students, or ancillary staffc. Demonstrate honesty, reliability, and integrity when dealing with

patients, attendings, families and peersd. Develop a commitment to the medical community and the

advancement of medical care in the populatione. Demonstrate compliance with the BRMC Professional Policy

7. Develop strong work habits:a. Be prompt in work, teaching, and patient care appointments.b. Demonstrate ability and commitment to use of continuing medical

education tools, such as journals, computer-assisted instruction, and involvement in conference activities both as learner and instructor

c. Recognize personal limitations and obtain appropriate assistance where necessary

d. Perform all record keeping activities promptly and thoroughlye. Understand requirements of operating in the managed care

environment, and how to maximize efficiencyf. Recognize the medico/legal aspects of care, and manage risks

appropriately





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4 CONTINUITY CLINIC

Goals: To create an Internal Medicine Clinic experience designed to prepare Internal Medicine Residents for Ambulatory Internal Medicine. The Clinic will facilitate the diagnostic and therapeutic skills of physicians in training utilizing patients representing the full spectrum of Internal Medicine. To provide primary and consultative Internal Medicine Services within the BRMC Clinics.

4.1 Overview

Internal Medicine residents are required to attend continuity clinic forty-four (44) weeks per academic year. The residents will be supervised by an attending internist during all sessions. Cases will be presented, discussed and all charts will be reviewed. The resident will be exposed to a broad spectrum of medical diagnoses and will be taught to apply the concepts of disease prevention and health maintenance.

Residents are required to enter their ambulatory patients in New Innovations that will be maintained in each resident’s personnel file. These logs must contain the patient’s medical record number, diagnosis and the activity and/or procedure performed on each visit.

Number of patients seen per half day period, will be as follows:

OGME-1= 2 new patient; 2 existing patientsOGME-2= 2 new patients; 4 existing patientsOGME-3= 2 new patients; 5 existing patients

Residents will maintain approximately fifty (50) patients per year in their patient panel.

Residents will be evaluated on a semi-annual basis using the 360° evaluation process. Residents will be evaluated by their attending physician, clinic staff and their patients.

The resident will be exposed to osteopathic concepts, behavioral and psycho-social aspects of medical care, medical ethics, medical-legal implications and practice management throughout the course of their training through lectures and discussions.

Residents will be notified of the patient’s admission and will follow their patient’s admission throughout the course of the patient’s stay.

Resident’s will be evaluated by the attending physician on their ability to perform a comprehensive history and physical examination, including structural examination for somatic dysfunction, pelvic exam, rectal exam, breast exam and male genital exam.

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4.2 Teaching Objectives

Residents will learn skills required to:

1. Provide Continuity Primary and Consultative Care 2. Office Procedural Skills3. Understanding and Proficiency in proper Documentation4. Understanding and Proficiency in Coding and Billing for services5. Weekly Didactics with focus on General Ambulatory Internal Medicine




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4.3 Continuity Clinic Evaluation

The resident will be evaluated quarterly on their patient evaluations and management, case presentation, productivity in the clinic, their compliance with clinic and residency policies and procedures, their compliance, accuracy and timeless of medical records, billing and coding and other administrative function along with their professionalism and ethical conduct.

A component of each resident’s evaluation will be their efforts at acquisition of knowledge through program and self-directed educational events. The resident evaluation will include how well they know the indications, contraindications, and risk for diagnostic and therapeutic procedures and their personal competency in performing clinical procedures and competencies expected of an osteopathic family physician in an outpatient setting. These include but not are limited to the clinical and psychosocial skills required to examine and obtain important and accurate medical information from a patient, splinting, taping, casting, laceration repairs, biopsies, I & D, rectal and pelvic examinations, joint injections, genital and rectal examinations on males, application of osteopathic manipulative treatments, etc.

The 360° continuity clinic evaluation is conducted at least twice each year by the Internal Medicine Residency Clinic trainer(s). The evaluation form is presented as a model, which utilizes the AOA core competency requirements.

Faculty in the continuity of care clinic will provide regular feedback to the residents in addition to the quarterly evaluations, highlighting strengths and weaknesses and pointing out areas that can be improved. The evaluation process should be an opportunity for teaching by the trainers resulting in personal and professional growth by the resident. Serious deficiencies need to be documented along with a plan for improvement.

The AOA has adopted the six core competencies with the inclusion in each section Osteopathic Principles and Concepts. This evaluation, along with the Resident Patient Evaluation, groups the questions into categories based on these competencies. While there is considerable overlap between the competencies, this format serves to illustrate how we are evaluating these items while acting as a guideline for shaping our curriculum.

Medical knowledge, clinical skills and patient care issues are paramount in most in-hospital setting and remain of critical importance in the ambulatory setting, but a successful physician needs more than good knowledge. Assessment of professionalism, cultural competency, practice management, risk management, and interpersonal communication is often just as important in the ambulatory setting.

A 360° evaluation compiles subjective information from several sources to obtain a ‘well rounded’ view of the resident. Evaluation forms may be filled out by the resident’s patients and peers, as well as by clinic faculty and staff. The clinic supervisor may decide how many evaluations to solicit, with the understanding that three (3) or more evaluations from each source will likely provide better data.

4.4 Clinic Didactics

Teaching during clinic sessions occurs informally during case presentation to supervising physicians as well as with discussion of various internal medicine topics as they pertain to the diagnoses of the patients seen in the clinic. Resident notes are reviewed by the supervising clinic attendings and teaching points are reviewed with the resident. The residents in the clinic are expected to attend all




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lectures scheduled in the teaching hospital, including morning report, noon lectures, Thursday Educational Days, etc.

4.5 Charting

Charting will be in standard SOAP format, either electronically produced, dictated, neatly hand written or standard forms. Additionally, clinical trials/research will be conducted from the Internal Medicine Clinic with additional documentation requirements being requested of the participating resident/preceptor. All charting by residents are reviewed and countersigned by the resident’s teaching attending and must be completed during the assigned clinic session before leaving. All charting and resident boxes will be completed prior to vacations or graduation.

Feedback regarding the resident’s documentation will occur during the clinic session and a compiled for inclusion in the resident’s annual performance review will be made.

4.6 Clinic “After Hours”

After hours the Chief Internal Medicine Resident in conjunction with the Clinic Director will arrange coverage. Schedules will be created and distributed on a quarterly basis. The hours of Internal Medicine Clinic Call are 5 p.m. – 9 a.m. Documentation of patient calls is mandatory. Call Logs will be distributed to residents for maintaining this documentation with copies placed on the patient chart. Calls requiring more detailed documentation will be dictated on the hospital stat dictation line and a message left at the clinic indicating the patient name, phone number and direction to the staff to obtain the dictated notation. If calling from your private phone, remember to first dial *67 to block caller ID.

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4.7 Procedures

Residents will develop proficiency in various procedures. The preceptor staffs all procedures performed in Internal Medicine Clinic. The resident is responsible for staffing and performing the procedure under the direct supervision of the attending physician, notification of the attending 24 hours prior to the procedure and dictation of procedure documentation.

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4.8 Vacation/Time Off from Clinic

All vacation requests will be filled in compliance with Medical Education Policies with a copy being provided to the Internal Medicine Clinic by the resident at least 4 weeks prior to the requested time. Any canceled clinic days require 2 weeks advanced notice and will be made up by the resident in discussion with the Clinic Director and staff. The only exception is emergencies, which require immediate notification of the Clinic Director.

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5 FLOOR RESPONSIBILITY

5.1 Electives

OGME-1 electives must be chosen at the beginning of the program year. The Director of Medical Education must approve all electives at least three months in advance.

Residents (OGME-2 and above) - Elective should be chosen at the beginning of the program year. The Program Director and the Director of Medical Education must approve all electives at least three months in.

BRMC requires all rotations to be arranged at the beginning of the academic year.

Prior to any elective rotations, the resident MUST confirm the elective with the Administrative Director of Medical Education to ensure all requirements for the elective have been met.

5.2 Night Coverage

Block night coverage is 7 p.m. to 7 a.m. Holiday and weekend nights coverage is 7 p.m. to 7 a.m., Saturday and Sunday are covered either in 12 or 24 hours blocks from 0700 Saturday until 0700 Monday.

Block night residents are expected to participate in all a.m. lectures throughout the year.

The attending physician on call is responsible for the admissions and must be contacted by the house officer. ED physicians and/or attending physicians are encouraged to call the house officer prior to each admission. OGME-1 residents are assigned admissions up to capped numbers and after evaluation must discuss cases with the senior resident.

Senior residents should use their own discretion, but it is always better to call than NOT call if there are any questions. Attending physicians are responsible for their patients and want to be informed of significant changes in their status.

All procedures are to be performed by a resident who has been “signed off” by their program director to perform the procedure. Prior to being “signed-off”, residents must have attending or senior resident - who him/herself has privileges to perform the procedure, supervise the procedure.

If the resident feels uncomfortable and/or feels they are in trouble, DO NOT get in over your head - ANTICIPATE. The resident should notify the appropriate resident on call in these situations and/or the attending physician for the patient.

5.3 Response to Floor Calls

Residents shall respond as soon as possible during the day or night when called to see a patient.

Instructions for giving medications and treatments may be given over the phone to the nurses only when the resident cannot report in person. Subsequently, he/she must respond when able and write all orders on the chart and sign and date. In addition, the resident must write a progress note on all patients requiring orders and evaluation.




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During the hours 7 a.m. to 7 p.m., floor call is directed to the resident directly caring for the patient. In their absence, the attending physician for the patient will be contacted. During the hours 7 p.m. to 7 a.m., floor call is directed to the OGME-1 resident assigned to nights. Patients will be seen ACCORDING TO HIGHEST PRIORITY FIRST. Critical care patients should be seen within one hour of admission. When handling a floor call, review the chart, pay attention to age, race, why the patient is here, what procedures have been done, vitals, and lab studies, then go see the patient. If indicated, do not be afraid to ask for a set of fresh vital signs. Then it is your responsibility to write the orders and a progress note (SOAP format). Finally, it is your responsibility to follow-up with the orders until you are sure the problem is solved - keep the attending notified of the patient’s status.

5.4 Rounds

The resident should make rounds on all assigned cases each morning and write his/her progress notes at that time. The house officers on the teaching service will make rounds with the attending staff and specifically with the staff member to whom he/she is assigned, on a daily basis. He/she will receive instruction, information, advice, suggestions and assistance from the staff who thus contributes to his/her bedside teaching. Prior to rounds, the resident should report to the attending physician all patients who present any new or unusual symptoms, unforeseen developments, emergencies or any dissatisfaction expressed by patients in regard to treatment, food, nursing, surroundings, or annoyances. After each patient visit, the house officer must make appropriate notes in the patient’s chart.

Assigned patients are to be visited as soon as possible after admission regardless of the hour. The attending physician is to be called at this time and be notified of the patient’s condition.

5.5 Admission

The process is presently set up to have admissions or the E.D.:

1. Provide the attending physician with name of the resident who is responsible for the admission at the time the admission is being called to the hospital. The attending physician should then, prior to the patient getting to the hospital, notify the responsible resident with information that is essential to facilitate the evaluation of the patient; such as labs, X-rays already done, severity of patients condition, consults, or other physicians who need to be notified.

2. Provide a more service-oriented admission process. 3. Provide for residents having the opportunity for evaluation and management of the patient,

not merely performing H & P’s. 4. Provide better resident supervision and education of students. 5. Improve communication between the residents and the attending physician. 6. Improved patient care and avoid untimely evaluation of severely ill patients.

In order to appropriately assign your patient to the correct house officer, they need to know:

1. The admitting physician’s name. 2. The preliminary diagnosis and unit of admission.3. Consulting physician(s) and levels of participation.

After evaluating the patient, the house officer doing the admission is to notify the attending physician of his/her findings and go over the appropriate orders.




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PLEASE NOTE: It is our desire to make sure the attending physician knows which resident is involved with the patients care to encourage the attending physician to notify the resident in charge of their admission of any information that may be helpful to him/her in facilitating the admission, i.e. needs to be seen right away, etc.

The Admitting Department needs only to notify the respective house officer that they are in charge of the admission, and that name should be on the face sheet.

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5.6 Admission Orders

After writing orders, return the chart to the Unit secretary or nurse caring for the patient. If you have written any STAT or now orders, notify the unit secretary or appropriate nurse so that undue delays do not occur. Always date, time and sign your orders. Include your printed name and pager number to facilitate nursing follow up of orders.

The American Osteopathic Association allows the attending physician to request consultations for his/her patient. This order must be written as the following:

a) Consultation only which leaves management to the attending physician and prohibits consultants from writing orders on the chart.

b) Consultation and management of a specific entity or procedure in which the consultant may write orders to manage the special entity or procedure but overall responsibility remains with the attending physician.

c) Consultation and co-management which permits the attending physician and the named physician to write orders, however, overall chart responsibility remains with the attending physician.

d) Consultation and full management where the consultant assumes full responsibility for writing orders and management of the patient and prohibits the attending physician from writing orders.

e) Transfer of management to another named physician in which case the patient care responsibilities in the hospital are transferred to the named physician and the admitting physician may no longer write orders.

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6 LOGS

Logging your activities is an essential part of any training program. Historically, it has been a challenge for the residents as well as trainers to have the paper work completed in a timely manner. We all tend to procrastinate with paperwork. It is an essential part of practice to adequately document your clinical work. It is a principal adopted by Medicare, third party carriers, as well as the legal profession that “if it is not documented – it did not happen”. To avoid frustration at the end of the year, and to enhance the satisfaction within a training program, it is extremely important that timely logging of clinical activities take place. Please review the American College of Osteopathic Internists’ requirement on logs.

It is important to realize the essential nature of logging. The principal objectives for this are:

1. Document to certifying agencies that you have accomplished a significant amount of clinical exposure and expertise to have graduated or to be certified and/or credentialed.

2. To document for the Department of Medical Education, the individual program directors and trainers, that the education program is serving their individual educational goals and providing the trainee with adequate opportunity to learn. Outside accrediting inspection agencies do, in the normal course of their review process, examine trainee logs.

3. To document your experience, for the purposes of applying for hospital privileges in the future. This point is the most important and concrete for the individual trainee. It is your personal future! Do not assume that by doing rotations at any particular institution that privileges will automatically flow so that logs need not be kept. Documentation is frequently important when providing letter of reference for future training programs and/or when applying for staff privileges. Frequently, individuals relocate on several occasions, and each new institution requires documentation of prior experiences.

4. Logs are due at the completion of the rotation. Time logs are due on the 1st of every month. Other logs and evaluations are due in within seven (7) days of completing the rotation.

5. All patient, educational and duty hour logs are to be entered into New Innovations.Appendices

6.1 Important Points to Remember

1. Responsibility of logs lies exclusively on the shoulders of the individual trainee, and is an American Osteopathic Association requirement for graduation from the program.

2. Log entries should be easily verifiable. It is a normal course of the hospital inspection for an inspector to request records. Charts are pulled for verification that the trainee participated in the care of a patient. Therefore, the logs should include some evidence of the level of involvement in the case. The medical record as well should reflect documentation of participation by the OGME-1 resident. Therefore, if multiple people are attending to a particular patient on a day that all parties contribute to the care, it should be noted on the medical record (i.e., attending/resident/intern/MSIV).

3. The responsibility for archiving the logs falls primarily on the shoulders of the trainee. The fact that the original copies are handed to the OGME Office, should not give the trainee a false sense of security that the documentation is safely stowed away. Record catastrophes do happen. It is; therefore, strongly emphasized that all logs and records be copied and retained in the residents’ personal possession. Photocopies are your personal insurance




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policy. In accordance with AOA policy, Bluefield Regional Medical Center is required to retain your logs for only five years.

6.2 What to Log

1. Any continuity clinic encounter should be recorded. Include the patient’s name, identification number, or other indicator as well as the diagnosis or multiple diagnoses and level of involvement.

2. Procedures are particularly important. Institutions, when credentialing, frequently request documentation of experiences. For this purpose, procedures are the most critical activities to be logged.

3. Any outside educational experience including: Academy meetings, educational seminars, and programs that are not held in-house or recorded in any other manner. We do maintain records internally of lectures, presentations and meetings. All activities out of the institutional walls would be lost unless included in your logs. On-call experiences are often looked upon as secondary activities, but are still a part of your net clinical experience. Therefore, they should be recorded as well.

6.3 How to Log

Be as specific as possible. Include name or initials, date, place, preceptor, and level of involvement. This last item is most important for procedures that you may want privileges for (i.e., observed 15 c-sections, participated or assisted in 20, did 2 under observation). All entries supported by hospital medical record number, date, time, location, preceptor, level of participation. You may want to mention complications or other related specifics that you handled.

In short, logs help to aid the function of the program, but most directly benefit you. Keep them current, and complete them in an organized manner. Do not procrastinate! The Program Director may call for the logs at any time during the year for spot review. They are your responsibility.

6.4 Policy Statement

To underscore the importance of this activity and to insure timely compliance, the policy on log and evaluation completion will be on the same basis as any medical record within the hospital. The educational objective here exceeds assuring mechanical compliance with submitting logs. It is designed to encourage a physician early in his/her career, the ability to follow through with the medical record in a timely manner. This is a shared expectation of all institutions that you will be involved with, so that it is appropriate to establish good habits from the beginning.

1. Patient logs and preceptor evaluations are to be entered into New Innovations within seven (7) days of completion of a rotation. Remember: LATE LOGS = SUBJECT TO DISCIPLINARY ACTION!

2. Time logs are entered into New Innovations and due immediately upon completion of the rotation.




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3. For longitudinal experiences that extend over the year period, it is expected that they be entered into New Innovations monthly and completed within fifteen (15) days of the completion of an academic year.

4. If logs are not completed in this timely manner, suspension from the education program may take place immediately upon direction of the Director of Medical Education.

5. Any time lost from the educational program will then be made up with compensatory time at the end of the educational program. A reminder – suspension also means that time off is not compensated time. So, adjustments will be made on the next pay check.

Exception to the rule:1. Catastrophic illness where the resident is not physically able to complete his/her logs.2. Catastrophic illness prohibits his/her preceptor from filling out the evaluation form.3. Consideration will be given to late reports only if an explanation is provided by the

preceptor, in writing, and accompanies the log and evaluation.

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7 MEDICAL DOCUMENTATION

The H & P is a working document and is essential for proper case management. It is a REQUIREMENT to visit the Medical Records Department WEEKLY to make sure your charts are up to date.

Always notify the attending physician regarding the admitted patient regardless if they have seen the patient or not.

If you have to leave the hospital for any reason, notify the attending physician, Department of Medical Education, Chief Residents, Chief Intern and Operators/Admitting Office and have another responsible intern or resident hold your pager and handle any of your floor calls (for day, morning, or afternoon off). If you need to get away for an hour or so, notify your attending physician, and get an intern or resident to handle your calls.

7.1 Patient Workups

Service and trainer: Patient workup assignments, whenever possible, will be in consideration of the service, and the trainers to whom the interns and students are assigned.

Priority of patient workup: Emergency admissions, surgical admissions and medical admissions.

Weekends: OGME-1 residents and students on weekend duty will pick up all admissions of that weekend up to service limits. The OGME-1 resident is to write ICU notes. Senior residents are responsible for supervision and to write a note.

Nights: The night resident is expected to do patient workups on emergency patients admitted through that department while on duty.

Patient workups are to be dictated within 24 hours of admission: To be completed before a patient is taken to surgery in all cases, and the night before surgery in elective cases.

Progress notes are written when the patient workup is completed, so stating, (e.g., “patient H&P dictated”) plus working and differential diagnosis.

Medical student physical workups are the responsibility of the OGME-1 resident on the service and are to be reviewed and countersigned by the OGME-1 resident, in addition to the attending physician. When no OGME-1 resident is assigned to the service, then the attending physician is primarily responsible.

Forms are available in the Medical Records Department for patient workups. Forms should be on the patient’s chart at the time of the workup. The advantage of the form is the availability of the patient workup on the chart. The disadvantage is that all patients are different and no one form fits all patients. So, when using a form, remember – add all pertinent information even though the form does not ask it. Make it complete, and make it fit the patient.

When you write in the progress note “patient workup dictated” add the information to that note. Then the attending physician is responsible and aware.

“Non-contributory”, “essentially negative”, “deferred”, “negative”, and “normal” may NOT be used unless specific to the disease, symptoms, sign or physical finding, (e.g., GI system normal” is




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not permitted. “Appetite normal” is permitted.) To physicians, attorney’s and regulatory authorities, WNL= We never looked!

When dictating, give patient’s name, spelling it if there is any question, sex, age, hospital number, attending physician and date. If using the form, include above. WRITE LEGIBLY and make all marks carefully and neatly so there is no mistaking what is meant. When dictating, follow the heading and format of the form.

When using the form, complete it by indicating each item as normal or abnormal. All items marked abnormal must be explained or described in the space provided. Additional facts or findings not specifically included in the form must be added when pertinent to the patient workup. This includes additional negative findings.

Certain items are to be answered by numbers such as OB digit system and blood pressure. Take the blood pressure yourself for your patient workup.

Put patient’s name and hospital number on the top of the hospital chart forms, including the history and physical for identification, in case the sheets are separated.

An osteopathic structural examination is to be done on all admission patients.

The provisional diagnoses are to include all established diagnoses, including obesity and hypertension, when diagnosable. Include diagnoses of the musculoskeletal system when present, whether primary or secondary.

All patient workups are to be signed to be considered complete.

7.2 Emergency Patient Workup

When time does not permit a full patient workup because of the emergency nature of the patient, you may do an emergency patient workup on the patient to expedite surgery. You are obliged to complete the patient workup as soon as possible.

This consists of a chief complaint, onset and course, allergies for the history and a general statement, heart and lungs, and the affected area for the physical in minimum.

7.3 Medical Documentation

Formal communication in medicine is achieved by documentation in the medical record to help maximize the quality of medical care among providers, support patient safety and risk management, support economic administration and minimizing liability.

It is essential to document all findings that are essential to the support of a diagnosis and rationale for evaluation or treatment. These findings may be positive or negative. All portions of the record should be consistent. That is the admitting note and the history and physical should refer to similar features. Usually the admission note is a more concise summary of what the important features found in the history and physical. The admit note further indicated clinical course and treatment plans. One should not simply refer between documents as “Note H&P”. In the process of the physical examination, it should be clear as to what was and was not examined.




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In the event an area was not included, it should not be stated that it was “deferred”, but rather an explanation as to why the examination was not performed should be made clear in the record. If a standardized medical form is being filled out, all areas of that respective form should be addressed in one way or another. Continuing progress notes need not necessarily address processes that are unchanged, but should detail an ongoing problem that is evolving. It is often better to make a general statement concerning impression than to attempt list of differential causes that may be incomplete. The generalized statement will suffice for the documentation and not waste effort and time.

One will occasionally come across a difficult situation where an unusual happening or adverse reaction has taken place. Avoid any commentary as to legal implications and restrict your comments only to what is relevant to the patient care and patient’s condition at the time. Keep the statement as factual as possible, never misrepresent facts, and do not attempt to colour them either positively or negatively. Use purely professional style in making your record entries. All documentation should be professional; never should you record unprofessional comments or attempt to be joking, overly melodramatic, blaming, or judgmental.

The medical record is not a location to “joust”, or carry on a medical debate between other health care practitioners. At all costs avoid any reference to blame, culpability, ability, or carelessness.

The professionalism, sincerity and credibility of your records are critical. First of all, they must always be legible. A record that is unreadable does not exist. If there is ever the occasion to change a medical record, it must be done carefully and in one of two potential ways:

1. It is to place a single line through the deleted material and initial, as well as dating the change. Never, ever destroy, re-write, cross out, obliterate, or make unrecognizable the original entry.

2. The second alternative in making a change in a medical record is to simply make a new note referring to the prior comment, document your correction and again – date, time and sign it.

If a patient has been injured or a medical complication has occurred, the appropriate mechanism of documenting that is in an incident report. This is legally undiscoverable as long as it is not referred to in the original document. In the medical chart – NEVER state that a risk management activity or an incident report has been filled out. Simply record the facts of the situation. If the incident involves any medical equipment, carefully preserve, but in no way alter or destroy it. Sequester it and make it available to the Risk Management authorities.

In dealing with the patient in terms of complication, it is always the physicians imperative to show concern for the welfare and comfort of the individual at hand. Initially, do not volunteer any admission of negligence or blame and avoid any statements that would imply that something has gone wrong until you have notified and discussed the problem with the attending physician. If an injury has occurred, never provide false statements or misleading expressions. Again, examine the patient and notify the attending physician. Although it is appropriate to avoid being overly solicitous, it is equally appropriate to show a reasonable amount of concern and empathy for the patient and family. Never ascribe blame to people, medical equipment, or situations. Doing so is often a reflex response that is given without objectivity and without the ability to consider all the influencing circumstances. As house staff personnel, it is always proper to refer a patient or concerned family member to the attending physician. They ultimately maintain the responsibility and also usually have the greatest rapport and understanding of the family/patient situation. If you feel uncomfortable in discussing the matter with the patient or family, it is best




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to avoid doing go. Make an appropriate referral to the attending physician or the individual in charge. Nursing supervisors and personnel often have a high level of experience in these matters and are often valuable resources. It is also very important to take preventive action. If a recognized potentially dangerous situation exists, take immediate action that would be necessary to protect the patient from potential injury, harm or any adverse effect. It is usually best to warn the attending physician. If you are aware of patient or family dissatisfaction of the health care efforts, bring this to the attention of the attending physician.

7.4 Medical Records

Always write with a blue or black pen, as some other colours of ink will not copy adequately for insurance and legal purposes. Write legibly!

1. Physical workups must be completed and recorded within 24 hours of admission (unless critical patient) or prior to surgery whichever comes first. Surgery workups should be written so that the medical information is readily available.

2. When a physical workup and H&P is performed, the resident should also produce a progress note. It is to be written immediately following the physical workup.

3. When responsible for an admitting progress note, it is to be written immediately following the physical workup.

4. When responsible for interval progress notes, they should be written every working day. If the condition of the patient changes during the day, extra progress notes are to be written.

5. Case summaries, when assigned, are to be done within 48 hours of discharge of the patient. Everything you write on the chart must be signed. When you write an order always include the name of the attending physician first, (e.g., James Monroe, D.O./Peter Smith, D.O.)

Remember – the admitting physician may not be the attending physician at the time.

6. Whenever writing orders, always explain the reason for your evaluation or treatment orders in a progress note.

7. All orders and progress notes must be dated, timed and signed.8. Medical records may be checked out of the Medical Record Department only for their use in

patient care or educational sessions. They may NEVER be taken out of the hospital.9. Physical workups may be delegated to a medical student; however, the intern/resident on

service will be directly responsible for the accuracy of such physical workup examinations and must countersign it.

10. All charts must be completed and signed within fifteen (15) days after the patient is discharged. Therefore, after seven (7) days, you will be considered delinquent in charting unless you are waiting for dictation to be typed. Medical Records will make your incomplete charts available to you at any time. If you are delinquent repeatedly, disciplinary action will be taken.

CHARTING IS A HABIT – Good or bad it is up to you!

7.5 Routine Progress Notes

1) Before writing progress notes, always identify your service. Conclude your note with your signature, printed name and pager number. Most of the services require daily progress




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notes, and the SOAP format is usually acceptable. However, an ICU progress note is almost as detailed as a new complete H&P.

2) Do not over-use abbreviations. When using abbreviations, follow the guidelines from the hospital manual.

3) On all admissions, please use the following guidelines:a) Progress notes, dated and timed, shall be written by all participating Physicians or

members of the house staff on all phases of a patient’s hospital stay. All progress notes should be in the SOAP format.

b) The admitting note (admitting summary) shall briefly state the chief complaint, the symptoms, and the physical findings that led to the working diagnosis, the expected therapy, and the possible consultations.

c) All significant physical changes, new signs and symptoms, complications, consultations, and treatment including manipulative therapy shall be recorded.

d) Progress notes shall describe in proper continuity, the course, progress, treatment, and disposition of the case.

e) Every progress note shall be signed by the house officer writing that note. The attending physician shall countersign your note after appropriate CMS documentation or may write his or her own progress note.

f) The final progress note, which includes the discharge summary, shall be performed by the house staff officer and signed or counter-signed by the attending physician.

7.6 Admitting Note

This note must briefly state the chief complaint, the symptoms and physical finding that lead to the working diagnosis, the expected diagnostic regimen, initial therapy and possible consultations; also, the prognosis as of that time.

7.7 Interval Notes: Off/End-of-Service Notes

These must cover current status and all significant physical changes since admission, new signs and symptoms, complications, consultations, procedures, results of diagnostic evaluations and significant treatment provided. They shall describe in proper continuity the course, progress, treatment and disposition of the case. Notes may have to be written several times a day, if the patient’s changing condition warrants it, or once a day may suffice on assigned cases.

All progress notes shall be dated, timed and signed by the physician writing them.

7.8 OMT Notes

Record all procedures, including OMT in a procedure note and refer to the procedure in the progress notes. Include the biomechanical diagnosis for which you are treating (e.g., “somatic dysfunction of _____ due to _____”). Date and time as you do for all progress notes. Record the result each time an OMM treatment is applied. If a series of treatments record summative results after several treatments.




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7.9 Discharge Summary

The note must include all information normally included in an end of service note in summary. This must include a review of the patient’s hospital stay, findings and treatment, his condition on discharge, and the disposition of the case. It shall describe the termination of the physician’s responsibility for the hospitalized patient, state whether the admission diagnosis and chief complaint have been resolved, discuss any complication that developed during the patient’s hospital stay, indicate whether diagnosis and treatment have been justified, or whether a diagnosis could not be established. Document discharge and follow up instructions, i.e. medications, diet, etc.

With regard to death, the matter of autopsy shall be discussed and all pertinent information obtained for the autopsy shall be recorded in accordance with State laws. If an autopsy is refused, the reasons for such refusal shall be stated. It is mandatory that OGME-1 resident write a discharge progress note on patients on their service.

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8 ACKNOWLEDGMENT

I acknowledge that I have received a copy of the Bluefield Regional Medical Center’s Internal Medicine Residency Manual, and I do commit to read and follow these policies.

I am aware that if, at any time, I have questions regarding Bluefield Regional Medical Center’s Internal Medicine Residency policies I should direct them to my Program Director, Director of Medical Education or the Administrative Director of Medical Education.

I know that Bluefield Regional Medical Center’s Internal Medicine Residency policies and other related documents do not form a contract of employment and are not a guarantee by Bluefield Regional Medical Center of the conditions and benefits that are described within them. Nevertheless, the provisions of such Bluefield Regional Medical Center policies are incorporated into the acknowledgment, and I agree that I shall abide by its provisions.

I also am aware that Bluefield Regional Medical Center, at any time, may on reasonable notice, change, add to, or delete from the provisions of the company policies.

________________________________ ___________________________Resident’s Printed Name OGME Level

________________________________ ___________________________Resident’s Signature Date

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9 APPENDICES

9.1 Personal Information Sheet9.2 Time Log9.3 Resident Continuity Patient Log9.4 Attending Evaluation of Resident Form9.5 Resident Evaluation of Faculty Form9.6 Time Away Request Form9.7 360° Evaluation Forms 9.8 IM Resident End-of-Year Checklist9.9 Employee Expense Reimbursement Form9.10 Patient Evaluation of Resident9.11 OGME-1 resident Evaluation of Resident9.12 Resident Exit Questionnaire



http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Inteval%20ofRes-IM.pdf

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Inteval%20ofRes-IM.pdf

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Pt%20Eval%20of%20Resident-IM.pdf

http://intranet.uhhs.com/files/step/Policy_Forms/Employee%20Expense%20Reimbursement%20Form.xls

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/IM%20Res%20End%20Yr%20Cklst.pdf

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Time-off%20request%20form.pdf

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Res%20Eval%20of%20Faculty-IM.pdf

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Attending%20Eval%20of%20Res-IM.pdf

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Res%20Continuity%20Log.pdf

http://admin.intranet.uhhs.com/files/RichmondHeightsDepartmentofMedicalEducation/Personal%20info%20form.pdf

internal medicine residency manual - bluefield regional medical center

Documents

dawn stull reviewedrevised

current version

dawn stull new

prior notice

time awayabsences

current copy

residents responsibility

future residents