General Surgery Section Raymond G. Murphy VA Medical ...

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General Surgery Section

Raymond G. Murphy VA Medical Center

Resident Guide

2016-2017

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Juliet Lopez MD

Stuar t Ford MD

Darra Kingsley MD

Reuben Last MD (rEUben)

Lorene Valdez-Boyle MD

Anthony Vigil MD, Chief of General Surgery

Stacey Schneider RN Nurse Manger

Janice Schwar tz Cancer Coordinator

RESIDENT GUIDE

GENERAL SURGERY SERVICE

RAYMOND G. MURPHY ALBUQUERQUE VA MEDICAL CENTER

TABLE OF CONTENTS

I. GOALS AND OBJECTIVES

A. MissionsoftheSection………………………….……pg4

B. PGYI…………………………………………….……pg5

C. PGYII…………………………………………..……..pg7

D. PGYIV/V…………………………………………….pg12

II. GENERAL

A. PoliciesandPrinciples……………………………….pg23

B. OrganizationandAdministration……………………pg23

C. Admissions…………………………………………..pg24

D. Discharges…………………………………………....pg24

E. WardServiceResponsibilities………………………..pg25

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F. OperatingRoom………………………………………pg27

G. ConsultationService………………………………….pg28

H. GeneralSurgeryClinic……………………………….pg30

I. WeeklyConferencesforResidents…………………..pg31

J. DutyHours…………………………………………...pg31

K. CallResponsibilities………………………………….pg32

III. WEEKLY SCHEDULE……………………………………pg 34

IV. ATTENDING SPECIFIC INFORMATION……………..pg 36-37

V. CONTACT INFORMATION……………………………...pg 38

VI. Attached Documents

a.Bloodtransfusionguidelines………………….pg41

b.IFYOUAREREADINGTHISYOUSHOULDALREADYHAVEYOURCPRSCODES!

i........................................................PG43

C. CPRSGuideforresidents…………………………pg44

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I. GENERAL SURGERY ROTATION GOALS AND OBJECTIVES

Itis aprivilegefortheAttendingGeneralSurgeonsandstaffintheGeneralSurgerySectiontoteachandtobeeducatedbythemedicalstudentsandresidentsonourservice.Ourmissionisunique---toprovidefirstclasscaretoourNation'sveterans.Wetakethatresponsibilityseriouslyandwehavetheexpectationthatyouwilldothesame.WetrustthatthishandbookwillbehelpfultoyouasyouexpandyourknowledgeofsurgicaldiseasesanditsmanagementaswellasprovideyouwithusefulinformationthatwillenhanceyourexperienceattheRaymondG.MurphyVAMedicalCenter.

A. MISSIONS OF THE SECTION

· Toprovidecomprehensivemedical,non-operative,minimallyinvasive(laparoscopic),andopensurgicaltreatmenttoVeteranswithsurgicaldiseasesoftheskin,softtissue,breast,abdomenandextremities.

· ToeducateourVeteransandtheirfamiliesabouttreatmentstopreventandreducetheriskfactorsassociatedwithsurgicaldiseasesandtoimplementcareplansthatfocusonthequalityoflifeforeachVeteranwithsurgicaldiseases.

· Toeducate,train,andmentormedicalstudentsandresidentsintheevaluation,treatment,andmanagementofVeteranswithsurgicaldiseases.N.B.TheprioritiesofMedicalStudentsare1.Tutorials/Lecturesand2.Getintooperatingroom.Theycansee2to4inpatients.Issues?PageDr.Vigil…

· Toperformevidenced-basedclinicalresearchthatadvancestheevaluationandtreatmentofVeteranswithsurgicaldiseases.

B. OBJECTIVES for PGY I Level

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Patient Carethatiscompassionate,appropriate,andeffectiveforthetreatmentofhealthproblemsandthepromotionofhealth

TheresidentshouldattendmorningroundsdailyonALL serviceandconsultpatients.TheresidentshouldbeabletosummarizethecareplanandhospitalizationcourseforALLserviceandconsultpatients.

Theresidentshouldperformexaminationandevaluationofnewpatients,peri-operativeandpostoperativecareofestablishedpatients,andsurgicalconsultationsunderthesupervisionofattendingsurgeons.Thiscareshouldoccurintheinpatientandoutpatientsettings,includingatleast½dayofweeklyclinics.

Theresidentshoulddemonstrateresponsibilityforthecareofallservicepatients,includingadmissionhistoryandphysicalexamination,daily progressnotes,anddischargesummaries.

Medical Knowledgeaboutestablishedandevolvingbiomedical,clinical,andcognate(e.g.epidemiologicalandsocial-behavioral)sciencesandtheapplicationofthisknowledgetopatientcare

Theresidentshouldbeabletorecognizeanddiagnosecommongeneralsurgeryproblemsandemergencies.

TheresidentshouldbeabletodemonstrateaccurateinterpretationofcommonradiographicabnormalitiesastheypertaintoGeneralSurgery.

Theresidentshouldbeabletodiscusstheindicationsandoutcomesforcommonoperationsanddemonstrateinformedconsent.

Practice-Based Learning and Improvementthatinvolvesinvestigationandevaluationoftheirownpatientcare,appraisalandassimilationofscientificevidence,andimprovementsinpatientcare

Demonstrateuseoftextbookandotherresourcestosupplementthelearningobtainedintheclinicalandconferencesetting.

TheresidentshouldrefertotheVAGeneralSurgeryRotationObjectivesfortheSeniorResidentandreflectonanindividuallearningplantoachievegradualcompetencyinmoreseniorobjectives.

Interpersonal and Communication Skillsthatresultineffectiveinformationexchangeandteamingwithpatients,theirfamilies,andotherhealthprofessionals

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Communicateinformationtoco-workers, faculty and consultantstoensurecontinuityofcare.

Discussmedicalerrorsorprofessionalmistakeshonestlyandopenlywithinthecontextofqualityimprovementtopromotepatientssafety,trust,andself-learning.

Theresidentshouldclearly,accurately,andrespectfullycommunicatewithpatientsandappropriatemembersoftheirfamilies,nursesandotherhospitalemployees,referringandconsultingphysicians,includingresidents.

Theresidentshouldmaintainclear,concise,accurate,andtimelymedicalrecordsincluding(butnotlimitedto)consultationnotes,progressnotes,writtenandverbalorders,operative notes, and discharge summar ies.

Professionalism,asmanifestedthroughacommitmenttocarryingoutprofessionalresponsibilities,adherencetoethicalprinciples,andsensitivitytoadiversepatientpopulation

Theresidentmustattendrequiredconferencesontime.

Theresidentmustenterallproceduresandoperativecasesinwhichhe/sheisthesurgeonofrecordintotheACGMECaseLogSystemwithin24hoursofcompletingtheprocedureoroperationornolaterthanweeklybyTuesdaysat7AM.

Theresidentmustdictateanaccurateanddescriptivenarrationoftheoperativeprocedureinwhichhe/sheistheprimarysurgeonwithin24hours.IftheAttendingwasnotscrubbedforentirecasepleasesay(ifrelevant)“forkeyandcriticalportionsofthecase.”

TheresidentmustmaintaincompliancewiththeACGMEDutyHoursrequirementsandmustinsurethatmembersofhisorherteammaintaincompliance.TheresidentmustdocumenthisorherdutyhoursintheNew-InnovationsSystemwithin24hoursofcompletingtheshiftornolaterthanweeklybyTuesdaysat7AM.

Systems-Based Practice,asmanifestedbyactionsthatdemonstrateanawarenessofandresponsivenesstothelargercontextandsystemofhealthcareandtheabilitytoeffectivelycallonsystemresourcestoprovidecarethatisofoptimalvalue

Theresidentshouldbeabletoapplytheappropriatedocumentationneededforcodingandbilling.

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Theresidentshoulddemonstrateappropriateuseofinstitutionalresources,suchassocialservice,homehealthcare,outpatientservices,etc.foreffectivedischargeplanning;andtobeabletobeginthisprocesswellinadvanceforefficientandpatient-orienteddischarge.

Thesegoalswillbemetbyperformingthefollowing:

1. ReadandunderstandtheResidentGuide.

2. ManageallGeneralpatientsontheserviceunderthedirectionoftheChiefResident/AttendingSurgeons.

3. Attenddailywardroundswiththeteam.

4. AttendallGeneralSurgeryClinicsasrequired(seeOutpatientClinicfordetails).

5. AttendandparticipateinthebimonthlyVADepartmentofSurgeryMorbidityandMortalityConferenceandthemonthlyUNMDepartmentofSurgeryConferences(seeWeeklySchedulefordetails)

6. AttendandparticipateinweeklyGeneralSurgeryConferences(seeWeeklySchedulefordetails).

7. Scrubinonalloperativecasesaspatientcareallows.

8. Readassignedmaterialsasdistributed.

C. OBJECTIVES for PGY II Level

TheGeneralSurgeryrotationisdesignedtopreparetheSeniorSurgicalResident(PGYIV/V)toindependentlyevaluateandsafelytreatpatientswithsurgicaldiseases.ThePGYIIlevelresidentshouldusetherotationasanopportunitytodevelopleadershipanddelegationskillsinthemanagementofpatientswithsurgicaldisease.TheChiefResident/PGYIV/Visresponsiblefortheday-to-dayoperationoftheGeneralSurgeryService:performingroundstwicedaily,supervisinganddirectingjuniorresidentsandmedicalstudents,preparingforMorbidityandMortalityandGeneralSurgeryConferences,andinformingtheAttending

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Surgeonsofmajorchangesinapatient’sstatusortherapy(transfertoICU,needfortransfusions,changesinantibiotics,consultationstootherservices,etc).ThePGYIIlevelresidentshouldconsiderhim/herselfasanextensionofthePGY/IVVresidentininsuringthattheseactivitiesoccur.WhiletheChiefResidentistoassumedirectorshipoftheserviceandisultimatelyresponsibleforthedelegation/assignment/completionofwork,thePGYIIlevelresidentshouldusetheChieflevelresidentasamodeltodevelopefficiencyandcommunicationskills.AlloftheclinicalfunctionswillbeperformedundertheguidanceanddirectsupervisionoftheAttendingGeneralSurgeons.JustasthePGYIV/Vlevelresident,thePGYIIlevelresidentwillseeEmergencyRoompatients,newpatientconsults,andoutpatientsintheGeneralSurgeryclinics.AllpatientsrequiringadmissionbytheAttendingSurgeonwillalsobeseenbythePGYIIlevelresidentwhenthePGYIIlevelresidentisthemostseniorresidentavailable.WhenthePGYIIlevelresidentisthemostseniorresidentavailable,e.g.duringweekendcoverage,he/sheisresponsiblefortherolesasnotedabove.InthissettingthePGYIIlevelresidentshouldformulateadetailedandcomprehensivemanagementplanonallpatientsadmittedtotheserviceandreviewtheplanwiththeAttendingGeneralSurgeon.ThePGYIIlevelresidentwillperformassignedoperationsunderthedirectsupervisionoftheAttendingGeneralSurgeon.Uponcompletionoftherotation,thePGYIIlevelresidentwillhaveamorecompleteworkingknowledgeofsurgicaldiseasesandtheirmedical,non-operativeandsurgicalmanagement.

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PLEASEEMAILDR.VIGILATANTHONY.VIGIL@VA.GOVEVERYTWOWEEKSORSOWITHEVALUATIONSOFSTUDENTSANDINTERNS.

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(TheseitemsmatchtheSCORECurriculumOutline)

Disease/Conditions:BROAD=agraduateshouldbeabletocareforallaspectsofdiseaseandprovidecomprehensivemanagement;FOCUSED=agraduateshouldbeabletomakethediagnosis,provideinitialmanagement/stabilization,butwillnotbeexpectedtobeabletoprovidecomprehensivemanagement.

Operations/Procedures:ESSENTIAL(Common)=frequentlyperformedoperationsingeneralsurgery;specificprocedurecompetencyisrequiredbyendoftraining(andshouldbeattainableprimarilybycasevolume);ESSENTIAL(Uncommon)=rare,oftenurgent,operationsseeningeneralsurgerypracticeandnottypicallydoneinsignificantnumbersrequiredbyendoftraining(butcannotbeattainedbycasevolumealone.);COMPLEX=notconsistentlyperformedbygeneralsurgeonintrainingandnottypicallyperformedingeneralsurgerypractice.

Theresidentshouldleadmorningroundsdailyonall serviceandconsultpatientswhenthePGY-5residentisonleaveandoncallweekends.Theresidentshouldbe

abletosummarizethecareplanandhospitalizationcourseforall serviceandconsultpatients.

Theresidentshouldperformexaminationandevaluationofnewpatients,peri-operativeandpostoperativecareofestablishedpatients,andsurgicalconsultationsunderthesupervisionofattendingsurgeons.Thiscareshouldoccurintheinpatientandoutpatientsettings,includingatleast½dayofweeklyclinics.

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Disease/Conditions:BROAD

Bythecompletionoftheculminationof(VAandUNM)GeneralSurgeryrotations,theresidentshouldbeableto care for all aspects of disease and provide comprehensive management forthefollowingconditions:Abdomen-General:acuteabdominalpain,intra-abdominalabscess,rectussheathhematoma,mesentericcyst;Abdomen-Hernia:inguinalhernia,umbilicalhernia,ventralhernia,miscellaneoushernias;Abdomen-Biliary:jaundice,cholangitis,gallstonedisease(acutecholecystitis,chroniccholecystitis,choledocholihtiasis,biliarypancreatitis,gallstoneileus),acalculouscholecystitisandbiliarydyskinesia,gallbladderneoplasms(polyps,cancer),iatrogenicbileductinjury;Alimentarytract-Esophagus:dysphagia,gastroesophagealrefluxandBarrett’sesophagus,hiatalhernia,esophagealperforation(spontaneous/iatrogenic),Mallory-Weisssyndrome;Alimentarytract-Stomach:upperGIbleeding,pepticulcerdisease(H.pyloriinfection,duodenalulcer,gastriculcer,bleeding,perforation,obstruction),gastricneoplasms(polyps,carcinoma,lymphoma,carcinoid),stressgastritis;Alimentarytract-SmallIntestine:smallbowelobstructionandileus,Meckel’sdiverticulum,Crohn’sdisease(emergencymanagement),radiationenteritis,smallbowelneoplasms(polyps,adenocarcinoma,lymphoma,carcinoid,GIST),intussusception,malrotation,pneumatosis,acutemesentericischemia(arterial/venous/nonocclusive);Alimentarytract-LargeIntestine:lowerGIbleeding,largebowelobstruction,acuteappendicitis,diverticulardisease(diverticulitis,diverticularbleeding,fistulae),volvulus,colonicneoplasms(polyps,colorectalcancer,miscellaneous),neoplasmsoftheappendix,inflammatoryboweldisease,(emergentmanagementofulcerative/indeterminatecolitis),ischemiccolitis,antibiotic-inducedcolitis;Alimentarytract-Anorectal:hemorrhoids,analfissure,anorectalabscessandfistulae,analcancer,rectalcancer;SkinandSoftTissue:nevi,melanoma,squamouscellcarcinomabasalcellcarcinoma,evaluationofsofttissuemasses,epidermalcyst,tumorsofdermaladenexae(apocrine,eccrinesebaceous,Merkelcell),dermatofibrosarcoma,skinandsofttissueinfections(hidradenitis,cellulitis,necrotizingfasciitis),handinfections(paronychia,felon),woundinfections,pilonidalcyst/sinus,intravenous and enteral access

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Disease/Conditions:FOCUSED

Bythecompletionoftheculminationof(VAandUNM)GeneralSurgeryrotations,theresidentshouldbeableto make the diagnosis, provide initial management/stabilization, but will not be expected to be able to provide comprehensive management forthefollowingconditions:Abdomen-General:chronicabdominalpain,peritonealneoplasms(carcinomatosis,pseudomyxomaperitoneii),spontaneousbacterialperitonitis,desmoidstumors,chylousascities,retroperitonealfibrosis;Abdomen-Biliary:gallbladdercancer,cancerofthebileducts,choledochalcyst,sclerosischolangitis,Alimentarytract-Esophagus:achalasia,diverticula(Zenker’s,epiphrenic),foreignbodies,Schatzki’sring,chemicalburns(ingestion),benignneoplasms,malignantneoplasms(adenocarcinoma,squamouscellcarcinoma),othermotilitydisorders(diffuseesophagealspasm,nutcrackeresophagus,presbyesophagus,sclerodermaconnectivetissuedisorders);Alimentarytract-Stomach:morbidobesity,bezoarsandforeignbodies,gastroparesis,postgastrectomysyndromes;Alimentarytract-SmallIntestine:shortbowelsyndrome,entericinfectionsandblindloopsyndrome;Alimentarytract-LargeIntestine:endometriosis,irritablebowelsyndrome,functionalconstipation,infectiouscolitis;Alimentarytract-Anorectal:pelvicfloordysfunction,incontinence,analdysplasia/sexually-transmitteddisease,rectalprolapse;SkinandSoftTissue:decubitusulcer,softtissuesarcomas(extremity,retroperitoneal),lymphedema;PlasticSurgery:aestheticsurgery(abdomen),abdominalwallreconstruction.

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Operations/Procedures:ESSENTIAL(Common)--BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshould achieve specific procedure competency (attainable primarily by case volume alone)forthefollowingprocedures:Abdomen-General:exploratorylaparotomy(open/laparoscopic);Abdomen-Hernia:repairinguinal/femoralhernia(open/laparoscopic),repairventralhernia(open/laparoscopic);Abdomen-Biliary:cholecystectomywith/withoutcholangiogram(open/laparoscopic);Abdomen-Liver:needle/wedgebiopsy(open/laparoscopic);Abdomen-Spleen:splenectomyfordisease(open/laparoscopic);Alimentarytract-Esophagus:laparoscopicantirefluxprocedure;Alimentarytract-Stomach:percutaneousendoscopicgastrostomy,opengastrostomy;Alimentarytract-SmallIntestine:smallbowelresection(open),adhesiolysis(open/laparoscopic),ileostomy,ileostomyclosure,feedingjejunostomy(open/laparoscopic);Alimentarytract-LargeIntestine:appendectomy(open/laparoscopic),partialcolectomy(open/laparoscopic),colostomy,colostomyclosure;Endoscopy:esophagogastroduodenoscopy,proctoscopy,colonoscopywithorwithoutbiopsy/polypectomy,bronchoscopy,laryngoscopy;SkinandSoftTissue:biopsy(excisionalandincisionalskin/softtissuelesions),incision,drainage,debridementforsofttissueinfection,pilonidalcystectomy;PlasticSurgery:skingrafting,intravenous and enteral access, nasogastr ic tube placement, central line placement, and ar ter ial line placement.

Operations/Procedures:ESSENTIAL(Uncommon)

BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshould achieve specific procedure competency (NOT usually attainable primarily by case volume alone)forthefollowingprocedures:Abdomen-General:opendrainageabdominalabscess;Abdomen-Hernia:repairmiscellaneoushernias;Abdomen-biliary:cholecystostomy,commonbileductexploration(open),choledochoscopy,choledochoentericanastomosis;operationforgallbladdercancer,repairacutecommonbileductinjury;Alimentarytract-Esophagus:openantirefluxoperation,open/laparoscopicrepairofparaesophagealhernia,repair/resectionofperforatedesophagus;Alimentarytract-Stomach:partial/totalgastrectomy,repairduodenalperforation,truncalvagotomyanddrainage;Alimentarytract-SmallIntestine:superiormesentericarteryembolectomy/thrombectomy;Alimentarytract-LargeIntestine:subtotalcolectomywithileorectalanastomosis/ileostomy;Alimentarytract-Anorectal:excisionofanalcancer;SkinandSoftTissue:widelocalexcisionmelanoma,sentinellymphnodebiopsyformelanoma,intubation, tracheostomy,


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Operations/Procedures:COMPLEX

BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshould attain knowledge in, but not specific procedural competency (most likely requiring the assistance of a reading or other educational program) forthefollowingprocedures:Abdomen-General:retroperitoneallymphnodedissection(open/laparoscopic),operationforpseudomyxoma;Abdomen-Hernia:componentseparationabdominalwallreconstruction;Abdomen-Biliary:laparoscopiccommonbileductexploration,operationforgallbladdercancer(planned),operationforbileductcancer,excisionofcholedochalcyst,transduodenalsphincteroplasty;Alimentarytract-Esophagus:esophagectomy(total),esophagogastroectomy,cricopharyngealmyotomywithexcisionofZenker’sdiverticulum,Hellermyotomy(open/laparoscopic),laparoscopicgastricresection,proximalgastricvagotomy,revisionalproceduresofpostgastrectomysyndromes;Alimentarytract-SmallIntestine:stricturoplastyforCrohn’sdisease;Alimentarytract-LargeIntestine:totalproctocolectomyandileoanalpull-through;Alimentarytract-Anorectal:stapledhemorrhoidectomy,repaircomplexanorectalfistulae,operationforincontinence/constipation,transabdominaloperationforrectalprolase(open/laparoscopic),perinealoperationforrectalprolapse,operationsforrectalcancer(transanalresection,abdominoperinealresection,pelvicexoneration);Endoscopy:mediastinoscopy,cystoscopy,ERCP;Endocrine:adrenalectomy(open/laparoscopic);SkinandSoftTissue:ileoinguinal-femorallymphadenectomy,majorresectionforsofttissuesarcoma.




Demonstratetheabilitytoaccess,analyze,andusethescientificliteratureduringdiscussionfortheGeneralSurgeryVAIndicationsConference(ThisoccursweeklyonThursdaymorningsat7am.)andGeneralSurgeryVAAttendingRounds(ThisoccursweeklyonFridaysatnoon.)


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Review with your Attendings and presentclearandconciseinformationmonthlytothesurgeryfacultyandresidentsattheVADepartmentofSurgeryMorbidityandMortalityConferenceandthemonthlyUNMDepartmentofSurgeryConferences.

PresentclearandconciseinformationweeklytothemultidisciplinaryTumorBoard.(ThisoccursweeklyonTuesdaysat1230.)Beawareofthepatient’sperformancestatus,livinglocale,andtumormarkers.

Communicateinformationtoco-workers,facultyandconsultantstoensurecontinuityofcare.



Theresidentshouldmaintainclear,concise,accurate,andtimelymedicalrecordsincluding(butnotlimitedto)consultationnotes,progressnotes,writtenandverbalorders,operativenotes,anddischargesummaries.


Theresidentmustattendrequiredconferencesontimeandinsurethatmembersofhisorherteamattendrequiredconferencesinatimelyfashion.




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Theresidentshouldbeabletodescribetherisks,benefitsandalternativesfortreatingpatientswithsurgicaldisease.



D. OBJECTIVES for PGY IV/V Level

TheGeneralSurgeryrotationisdesignedtopreparetheSeniorSurgicalResident(PGYIV/V)toindependentlyevaluateandsafelytreatpatientswithsurgicaldiseases.TheChiefResident/PGYVisresponsiblefortheday-to-dayoperationoftheGeneralSurgeryService:performingroundstwicedaily,supervisinganddirectingjuniorresidentsandmedicalstudents,preparingforMorbidityandMortalityandGeneralSurgeryConferences,andinformingtheAttendingSurgeonsofmajorchangesinapatient’sstatusortherapy(transfertoICU,needfortransfusions,changesinantibiotics,consultationstootherservices,etc).TheChiefResident/PGYIV/Viswillassumedirectorshipoftheserviceandhe/sheisultimatelyresponsibleforthedelegation/assignment/completionofwork.AllofthesefunctionswillbeperformedundertheguidanceanddirectsupervisionoftheAttendingGeneralSurgeons.TheChiefResident/PGYVwillseeallEmergencyRoompatients,allnewpatientconsults,andoutpatientsintheGeneralSurgeryclinics.AllpatientsrequiringadmissionbytheAttendingSurgeonwillalsobeseenbytheTheChiefResident/PGYIV/V.TheChiefResidentshouldformulateadetailedandcomprehensivemanagementplanonallpatientsadmittedtotheserviceandreviewtheplanwiththeAttendingGeneralSurgeon.TheChiefResidentwillperformassignedoperationsunderthedirectsupervisionoftheAttendingGeneralSurgeon.Uponcompletionoftherotation,theSeniorSurgicalResident(PGYIV/V)shouldhaveacompleteandthoroughworkingknowledgeofsurgicaldiseasesand

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theirmedical,non-operativeandsurgicalmanagement.ThePGYIV/Vresidentisresponsiblefortherolesasnotedabovewhencross-coveringontheGeneralSurgeryService.

PLEASEEMAILDR.VIGILATANTHONY.VIGIL@VA.GOVEVERYTWOWEEKSORSOWITHEVALUATIONSOFSTUDENTSANDJUNIORRESIDENTSANDINTERNS.


(TheseitemsmatchtheSCORECurriculumOutline)

Disease/Conditions:BROAD=agraduateshouldbeabletocareforallaspectsofdiseaseandprovidecomprehensivemanagement;FOCUSED=agraduateshouldbeabletomakethediagnosis,provideinitialmanagement/stabilization,butwillnotbeexpectedtobeabletoprovidecomprehensivemanagement.

Operations/Procedures:ESSENTIAL(Common)=frequentlyperformedoperationsingeneralsurgery;specificprocedurecompetencyisrequiredbyendoftraining(andshouldbeattainableprimarilybycasevolume);ESSENTIAL(Uncommon)=rare,oftenurgent,operationsseeningeneralsurgerypracticeandnottypicallydoneinsignificantnumbersrequiredbyendoftraining(butcannotbeattainedbycasevolumealone.);COMPLEX=notconsistentlyperformedbygeneralsurgeonintrainingandnottypicallyperformedingeneralsurgerypractice.

Theresidentshouldleadmorningroundsdailyonallserviceandconsultpatients.Theresidentshouldbeabletosummarizethecareplanandhospitalizationcourseforallserviceandconsultpatients.

Theresidentshouldperformexaminationandevaluationofnewpatients,perioperativeandpostoperativecareofestablishedpatients,andsurgicalconsultationsunderthesupervisionofattendingsurgeons.Thiscareshouldoccurintheinpatientandoutpatientsettings,includingatleast½dayofweeklyclinics.

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Disease/Conditions:BROAD

BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshouldbeableto care for all aspects of disease and provide comprehensive management forthefollowingconditions:Abdomen-General:acuteabdominalpain,intra-abdominalabscess,rectussheathhematoma,mesentericcyst;Abdomen-Hernia:inguinalhernia,umbilicalhernia,ventralhernia,miscellaneoushernias;Abdomen-Biliary:jaundice,cholangitis,gallstonedisease(acutecholecystitis,chroniccholecystitis,choledocholihtiasis,biliarypancreatitis,gallstoneileus),acalculouscholecystitisandbiliarydyskinesia,gallbladderneoplasms(polyps,cancer),iatrogenicbileductinjury;Alimentarytract-Esophagus:dysphagia,gastroesophagealrefluxandBarrett’sesophagus,hiatalhernia,esophagealperforation(spontaneous/iatrogenic),Mallory-Weisssyndrome;Alimentarytract-Stomach:upperGIbleeding,pepticulcerdisease(H.pyloriinfection,duodenalulcer,gastriculcer,bleeding,perforation,obstruction),gastricneoplasms(polyps,carcinoma,lymphoma,carcinoid),stressgastritis;Alimentarytract-SmallIntestine:smallbowelobstructionandileus,Meckel’sdiverticulum,Crohn’sdisease(emergencymanagement),radiationenteritis,smallbowelneoplasms(polyps,adenocarcinoma,lymphoma,carcinoid,GIST),intussusception,malrotation,pneumatosis,acutemesentericischemia(arterial/venous/nonocclusive);Alimentarytract-LargeIntestine:lowerGIbleeding,largebowelobstruction,acuteappendicitis,diverticulardisease(diverticulitis,diverticularbleeding,fistulae),volvulus,colonicneoplasms(polyps,colorectalcancer,miscellaneous),neoplasmsoftheappendix,inflammatoryboweldisease,(emergentmanagementofulcerative/indeterminatecolitis),ischemiccolitis,antibiotic-inducedcolitis;Alimentarytract-Anorectal:hemorrhoids,analfissure,anorectalabscessandfistulae,analcancer,rectalcancer;SkinandSoftTissue:nevi,melanoma,squamouscellcarcinomabasalcellcarcinoma,evaluationofsofttissuemasses,epidermalcyst,tumorsofdermaladenexae(apocrine,eccrinesebaceous,Merkelcell),dermatofibrosarcoma,skinandsofttissueinfections(hidradenitis,cellulitis,necrotizingfasciitis),handinfections(paronychia,felon),woundinfections, pilonidal cyst/sinus, intravenous and enteral access

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Disease/Conditions:FOCUSED

BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshouldbeableto make the diagnosis, provide initial management/stabilization, but will not be expected to be able to provide comprehensive management forthefollowingconditions:Abdomen-General:chronicabdominalpain,peritonealneoplasms(carcinomatosis,pseudomyxomaperitoneii),spontaneousbacterialperitonitis,desmoidstumors,chylousascities,retroperitonealfibrosis;Abdomen-Biliary:gallbladdercancer,cancerofthebileducts,choledochalcyst,sclerosischolangitis,Alimentarytract-Esophagus:achalasia,diverticula(Zenker’s,epiphrenic),foreignbodies,Schatzki’sring,chemicalburns(ingestion),benignneoplasms,malignantneoplasms(adenocarcinoma,squamouscellcarcinoma),othermotilitydisorders(diffuseesophagealspasm,nutcrackeresophagus,presbyesophagus,sclerodermaconnectivetissuedisorders);Alimentarytract-Stomach:morbidobesity,bezoarsandforeignbodies,gastroparesis,postgastrectomysyndromes;Alimentarytract-SmallIntestine:shortbowelsyndrome,entericinfectionsandblindloopsyndrome;Alimentarytract-LargeIntestine:endometriosis,irritablebowelsyndrome,functionalconstipation,infectiouscolitis;Alimentarytract-Anorectal:pelvicfloordysfunction,incontinence,analdysplasia/sexually-transmitteddisease,rectalprolapse;,intravenous and enteral access, nasogastr ic tube placement, central line placement, and ar ter ial line placement, SkinandSoftTissue:decubitusulcer,softtissuesarcomas(extremity,retroperitoneal),lymphedema;PlasticSurgery:aestheticsurgery(abdomen),abdominalwallreconstruction.

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Operations/Procedures:ESSENTIAL(Common)--BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshould achieve specific procedure competency (attainable primarily by case volume alone)forthefollowingprocedures:Abdomen-General:exploratorylaparotomy(open/laparoscopic);Abdomen-Hernia:repairinguinal/femoralhernia(open/laparoscopic),repairventralhernia(open/laparoscopic);Abdomen-Biliary:cholecystectomywith/withoutcholangiogram(open/laparoscopic);Abdomen-Liver:needle/wedgebiopsy(open/laparoscopic);Abdomen-Spleen:splenectomyfordisease(open/laparoscopic);Alimentarytract-Esophagus:laparoscopicantirefluxprocedure;Alimentarytract-Stomach:percutaneousendoscopicgastrostomy,opengastrostomy;Alimentarytract-SmallIntestine:smallbowelresection(open),adhesiolysis(open/laparoscopic),ileostomy,ileostomyclosure,feedingjejunostomy(open/laparoscopic);Alimentarytract-LargeIntestine:appendectomy(open/laparoscopic),partialcolectomy(open/laparoscopic),colostomy,colostomyclosure;Endoscopy:esophagogastroduodenoscopy,proctoscopy,colonoscopywithorwithoutbiopsy/polypectomy,bronchoscopy,laryngoscopy;SkinandSoftTissue:biopsy(excisionalandincisionalskin/softtissuelesions),incision,drainage,debridementforsofttissueinfection,pilonidalcystectomy;PlasticSurgery:skingrafting intravenous and enteral access, nasogastr ic tube placement, central line placement, and ar ter ial line placement..

Operations/Procedures:ESSENTIAL(Uncommon)

BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshould achieve specific procedure competency (NOT usually attainable primarily by case volume alone)forthefollowingprocedures:Abdomen-General:opendrainageabdominalabscess;Abdomen-Hernia:repairmiscellaneoushernias;Abdomen-biliary:cholecystostomy,commonbileductexploration(open),chodoschoscopy,choledochoentericanastomosis;operationforgallbladdercancer,repairacutecommonbileductinjury;Alimentarytract-Esophagus:openantirefluxoperation,open/laparoscopicrepairofparaesophagealhernia,repair/resectionofperforatedesophagus;Alimentarytract-Stomach:partial/totalgastrectomy,repairduodenalperforation,truncalvagotomyanddrainage;Alimentarytract-SmallIntestine:superiormesentericarteryembolectomy/thrombectomy;Alimentarytract-LargeIntestine:subtotalcolectomywithileorectalanastomosis/ileostomy;Alimentarytract-Anorectal:excisionofanalcancer;SkinandSoftTissue:widelocalexcisionmelanoma,sentinellymphnodebiopsyformelanoma. intubation, tracheostomy, Swan Ganz Catheter ization

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Operations/Procedures:COMPLEX

BythecompletionoftheculminationofGeneralSurgeryrotations,theresidentshould attain knowledge in, but not specific procedural competency (most likely requiring the assistance of a reading or other educational program) forthefollowingprocedures:Abdomen-General:retroperitoneallymphnodedissection(open/laparoscopic),operationforpseudomyxoma;Abdomen-Hernia:componentseparationabdominalwallreconstruction;Abdomen-Biliary:laparoscopiccommonbileductexploration,operationforgallbladdercancer(planned),operationforbileductcancer,excisionofcholedochalcyst,transduodenalsphincteroplasty;Alimentarytract-Esophagus:esophagectomy(total),esophagogastroectomy,cricopharyngealmyotomywithexcisionofZenker’sdiverticulum,Hellermyotomy(open/laparoscopic),laparoscopicgastricresection,proximalgastricvagotomy,revisionalproceduresofpostgastrectomysyndromes;Alimentarytract-SmallIntestine:stricturoplastyforCrohn’sdisease;Alimentarytract-LargeIntestine:totalproctocolectomyandileoanalpull-through;Alimentarytract-Anorectal:stapledhemorrhoidectomy,repaircomplexanorectalfistulae,operationforincontinence/constipation,transabdominaloperationforrectalprolase(open/laparoscopic),perinealoperationforrectalprolapse,operationsforrectalcancer(transanalresection,abdominoperinealresection,pelvicexoneration);Endoscopy:mediastinoscopy,cystoscopy,ERCP;Endocrine:adrenalectomy(open/laparoscopic);SkinandSoftTissue:ileoinguinal-femorallymphadenectomy,majorresectionforsofttissuesarcoma.




Demonstratetheabilitytoaccess,analyze,andusethescientificliteratureduringdiscussionfortheGeneralSurgeryVAIndicationsConference(ThisoccursweeklyonThursdaymorningsat7am.)andGeneralSurgeryVAAttendingRounds(ThisoccursweeklyonFridaysatnoon.)

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Review with your Attendings and presentclearandconciseinformationmonthlytothesurgeryfacultyandresidentsattheVADepartmentofSurgeryMorbidityandMortalityConferenceandthemonthlyUNMDepartmentofSurgeryConferences.

PresentclearandconciseinformationweeklytothemultidisciplinaryTumorBoard.(ThisoccursweeklyonTuesdaysat1230.)Beawareofthepatient’sperformancestatus,livinglocale,andtumormarkers.

Communicateinformationtoco-workers,facultyandconsultantstoensurecontinuityofcare.



Theresidentshouldmaintainclear,concise,accurate,andtimelymedicalrecordsincluding(butnotlimitedto)consultationnotes,progressnotes,writtenandverbalorders,operativenotes,anddischargesummaries.

Theresidentshouldbeabletoteachmedicalstudentsandjuniorresidentsabouttheproceduresperformedonthisrotation.Theyshouldbeabletocounselpatientsandappropriatemembersoftheirfamiliesinordertoobtaininformedconsent.


Theresidentmustattendrequiredconferencesontimeandinsurethatmembersofhisorherteamattendrequiredconferencesinatimelyfashion.


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Theresidentshouldbeabletodescribetherisks,benefitsandalternativesfortreatingpatientswithsurgicaldisease.

Theresidentshouldbeabletosummarizethefinancialcosts,potentialcomplications,andlong-termexpectationsforplannedprocedures.



E. Initial and Final Rotation Evaluations

AllsurgicaltraineesontheservicewillhaveaninitialandfinalrotationevaluationwiththeAttendingSurgeons.ThepurposeoftheinitialmeetingwiththeAttendingSurgeonsistoreviewthesectiongoalsandobjectivesandtodeterminetheneedsoftheindividualtraineeandsetpersonalgoalsfortherotation.FinalrotationevaluationswillbecompletedviaNewInnovationsandprovidedtotheresidentsthroughthat

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system.Residentsontheservicemayrequestanevaluationatanytimetoreviewtheirprogress,particularlywhendeficiencieshavebeennoted.

II. GENERAL

A. POLICIES AND PRINCIPLES

1.Patient care is the fir st pr ior ity.

OurgoalisthatallpatientsontheGeneralSurgerySectionareprovidedthebestpossiblecare.Thewelfareofourveteransandthequalityofthemedicalservicesprovidedarethecombinedresponsibilityoftheresidents,medicalstudents,thesupportstaff,andtheattendingGeneralsurgeons.

2.Education is a vital par t of the everyday operation of the service.

Medicalschoolsandsurgicalresidenciesexistforthepurposeofprovidingmedicaleducationandprofessionaltraining.Asphysiciansandphysicians-in-training,eachofusisresponsiblefortheeducationofothermedicalandparamedicalpersonnel,ourpatients,andtheirfamilies.Pleaseprovideagoodexampletomedicalstudentsbynotcuttingandpastingnotesfromthepriornote:thisisannoyingtoreadandawasteoftimeforthereader.

Forsurveypurposesandbestpractices:

• beremindedthatwehave4regularlyschedulededucationalconferenceshereattheVAforgeneralsurgerylearners.

• Feelfreetoremindlearnerswhenyouaregivingthemfeedbackorteachingthem.

• Readingthishandbookisahugepartofyour‘goalsandexpectations’.

3.Research oppor tunities are available to any interested medical student or resident.

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ThecommitmentoftheAttendingGeneralSurgeonsisforthetraineetodevelopandbementoredthrougharesearchprojecttoproduceapapersuitableforpresentationatalocal,regional,ornationalmeetingandsuitableforpublicationinapeer-reviewedjournal

B. ORGANIZATION AND ADMINISTRATION

AnAttendingGeneralSurgeonsupervisesallpatientcare.TheChiefResident/PGYVhasgeneralresponsibilityfortheserviceincludinginpatientpreoperativeandpostoperativecareaswellasoutpatientcareintheGeneralSurgeryClinic.Thejuniorresidents,inconjunctionwithnon-physicianprovidersassignedtotheservice,aretheprimaryphysiciansresponsibleforallaspectsofGeneralSurgerypatients’evaluationandtreatment.Juniorresidentsareexpectedtotakeanactiveroleinallpatientcareactivities.Thegeneralruleisthatindependentthought,not independent action,isencouraged.Onceyoumakeamanagementplanorchangeacurrentplan,protectyourselfandyourpatientsbydiscussingitwithsomeonemoreseniortoyoubeforeyouputyourplanintoaction.ItmaymeangoingIntotheOR,Gastroenterologysuite,orotherlocale,todiscussassoonaspossible.Theresidentteamshouldmeetinpersonforpatientcarecoordinationamongallinvolved.ResidentsaretocarrytheGeneralSurgerypager(251-0120)atalltimes(When possible the pager should remain out of the OR if another responsible provider is available to car ry the pager .)

C. ADMISSIONS

Alladmissionsmustbescheduled,coordinated,andapprovedbyanAttendingGeneralSurgeon.Thisincludesadmissionsfromtheclinic,telephonereferrals,hospitaltransfers,andadmissionsfromtheEmergencyDepartment.ResidentsmayNOTtakeoutside/transfercalls.Outside/transferprovidersshouldbereferredtotheAdministratoronDuty(AOD)sothatVAprocessfortransferscanbefollowedtheappropriateAttendingprovidercontacted.Admissionsfromtheclinicarefacilitatedthroughoursectionnurse,Ms.StaceySchneider-5867.Outpatientconsultations,ASUpreoperativeappointments,andfollow-upappointmentsarecoordinatedwithMs.Schneideroroursecretaryatext2776.Patientsarenotplacedontheoperativescheduleuntilallofthenecessarypreoperativeevaluationsandconsultationsarecompleted.

ConsultationsfromtheEmergencyDepartment,bothduringdutyhoursandafterhours,shouldbeseenbytheresidentwithin30minutesoftheconsultrequest.BesureorgentlyremindtheconsultingtoprovidertoputtheconsultrequestintheCPRScomputerchart.Afterthepatienthasbeenseenandevaluated,theon-callAttendingGeneralSurgeonshouldbenotifiedandplanofcaredeveloped

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USE‘STANDARD’HANDPFORANYPATIENTTOBEADMITTED-FILLOUTALLREQUIREDBOXES,WHETHERWITHN/AORWHATEVERAPPROPRIATE.

UseACUTECAREHOSPICESERVICEasyouradmittingserviceforanypatientthatisunlikelytosurvive,foranyreason,thenext6months.Usethesurgicalattendingofrecordastheattending.

D. DISCHARGES

AllpatientdischargesneedtheapprovalofanAttendingGeneralSurgeon.Arrangementsforpatientfollow-upshouldbecompletedbeforethetimeofdischarge.Planningfordischargeincludes:

1. Completingdischargeprescriptionsandpatientinstructionregardingrequiredmedications.Mostwillautomaticallyneedastoolsoftenerforonemonth.

2. Dietandactivityinstructions.

3. Woundcareinstructionsandprovisionsofdressingsupplies

4. Assuringthatpatients’socialneedshavebeenaddressed.(e.g.travelandhomecarearranged,instructionstofamily, etc.)

5. Makingfollow-upappointmentsfortheGeneralSurgeryClinic.Ifthepatientisbeingdischargedatnightoronaweekend,pleasemakesurethatthepatientinformationisplacedatthebottomofthePatientListsothatanappropriatefollow-upappointmentcanbearrangedthefirstworkdayback(usuallyMonday).

6. Institutionpolicyisthatabovebecompletedthedaypriorsothepatientcanmeetthedischargetimeof11:00AMthefollowingday.

7. Anypatientgettingatransfusionthatweorderedwillneedatransfusionepisodenote.ThenotemusthavetheindicationsandtheCLINICALresponsetothetransfusion.Anytransfusionordermustbediscussedwiththeattending.

Atthetimeofdischarge,allappropriatedischargepaperwork(1-outpatient/dischargemedicationsorsuppliesRx,2-"DischargeInstructions"noteinCPRS,whichwillauto-generatea3-"Discharge"orderanda4-"DischargeSummary")mustbecompletedinCPRSandthedischargingresidentMUSTdictateadischargesummaryin

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24hrs.IfthereareanyquestionswithregardtotheadministrativerequirementsattheVAforpatientdischarge,pleasedirectthemtotheappropriateAttendingGeneralSurgeon.

Dcnoteneedstobecompletedpriortoptdc.

Dischargeprogressnoteelementmustinclude:1.Conditionofpatientatdctoincludewound,ifapplicable

2.Ptreadinessfordcappropriate

Dischargesummariesmusthave:operations,procedures,treatmentsrenderedwiththedates

E. WARD SERVICE RESPONSIBILITIES

1.ThehistoryandphysicalexaminationmustberecordedinCPRSattheVAuponadmission.Ifamedicalstudentperformsthehistoryandphysical,itmustbereviewedandcountersignedbyasupervisingresidentorattending.Thehistoryandphysicalexaminationmustbecompletedwithin24hrsofadmissiontothewardandisarequirementbeforetransfertotheoperatingroom.Ifthepatienthashadahistoryandphysicalintheclinicpriortoelective/preoperativeadmission(andwithin30daysoftheadmission),a"GeneralSurgeryInpatient"noteoranaddendumshouldbemadetothehistoryandphysicaltoreflectthepatient'scurrentstatusatadmission.

2.Patientroundsshouldbeconductedatleasttwicedaily.Aphysicianshouldrevieweachpatient’scourse,problems,andneeds--morningandevening.TheChiefResident/PGYVisresponsibleforcoordinatingworkroundsinthemorningandintheevening.TheChiefResident/PGYVordelegateshoulddiscussthedailycareplanwiththesupervisingattending(s)followingmorningrounds.Iftherearechangestothepatient'sstatusortest/studyresultstoreport,thesupervisingattendingshouldbenotified.Intheafternoon,theChiefResidentshouldtouchbasewitheachofthesupervisingattendings,sothatappropriateattending-to-attendingcheck-outcanoccur.

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3.Allpatientsrequireappropriatedailyprogressnotesrecordedinthemedicalrecord.Thesenotesshouldbeconciseanddescribeonlysignificantcomplaints,findings,investigationsordevelopments.Themostimportantentriesarethosethatexplainwhatdecisionsweremadeaboutthepatient’smanagementandwhy.TheGeneralSurgeryAttendingassignedtothepatientshouldusuallybetheco-signerforthesenotes.OntheweekendsandholidaystheGeneralSurgeryAttendingassignedforcallshouldbetheco-signer.Pleasecommunicatethistotheinterns,students,andoff–serviceresidents.

4.Allprogressnotesandorderswrittenbymedicalstudentsmustbecountersignedbyasupervisingresidentassoonaspossible.Thisisparticularlyimportantfororders,aspolicyprohibitsnursesfromcarryingoutmedicalstudents’ordersthathavenotbeencountersigned.

5.AllpatientsscheduledforsurgeryMUSThaveapreoperativenoteannotatedinthechart.Inmostcases,thisnotewillbewrittenbytheindividualexpectedtoperformtheoperation.Thisnoteshouldbrieflydescribetheplannedprocedureandtherationaleforit.Thenoteshouldclearlystatethattherisksoftheprocedurehavebeenexplained,aswellasthealternativetreatmentoptions,andthatthepatientindicatedthathe/sheunderstoodandgaveconsent.ThepreoperativenoteshouldalsoindicatewhichAttendingGeneralSurgeonhasreviewedthecaseandapprovedtheplan.Apreoperativereviewshouldbedonetoensurethatallnecessarypreoperativeevaluationsarecompleteandthatthepatientisadequatelypreparedfortheoperation.

6.Proceduralconsentformsforoperationshouldbecompletedbytheindividualexpectedtoactasthesurgeon.AllGeneralSurgeryAttendingsaretobelistedontheconsentform.Toobtainaninformedconsent,theresidentmustbesufficientlyfamiliarwiththeoperationplanned(anditspotentialcomplications)toanswerthepatient’squestions.ConsentformsattheVAarecompletedelectronicallyinCPRSunderiMEDConsent.TheconsentformsspecifictoGeneralSurgerycaneitherbefoundundertheGeneralSurgeryorGastroenterologyprocedurelists.TheiMedConsent(notpaperconsent)isexpectedtobecompletedpriortoanyscheduledprocedure(within60daysoftheplannedoperation)sothatappropriatequestions/concernsoftheveteranandhis/herfamilycanbeaddressed.IfiMedConsentisnotavailable,apaperconsentcanbecompleted(formsareavailableon3AandintheSICU)withanoteindicatingthereasonthattheiMedConsentcouldnotbecompletedannotatedinCPRS.

F. OPERATING ROOM

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Electivesurgicalandgeneralmustbecompletedelectronically3businessdayspriortothedayofsurgeryby10:00AM-pleasenoteholidays.Ifthecaseisnot‘highlighted’itisnotlistedinthecomputer.EmergencyandaddoncaseschedulingiscompletedbyfillingoutapaperrequestavailableattheOperatingRoomfrontdeskanddeliveredtothechargenurseintheOperatingRoomoranotherresponsiblepartyattheOperatingRoomfrontdesk.

BecauseOperatingRoomtimeandresourcesareatapremium,itisparamountthateverythingpossiblebedonetoassureefficiency.BoththepatientandthesurgeonshouldbepreparedfortheoperationbeforeenteringtheOperatingRoom.Allpatientsmustbeappropriatelysitemarkedpre-operativelybyamemberoftheoperativeteamwhowillbeparticipatingintheoperatingroom(notamedicalstudent)intheASUorPACUorintheEmergencyDepartmentorSICU/etc.Firstcasesofthedaymustbemarkedby7:10AMbytheattending!Anyspecialrequirementsshouldbeaddressedaheadoftime.TheOperatingRoomstaffshouldbebriefedaboutunusualequipment,supplies,positioningortechnicalconsiderationsbothverballyandinwritingwhenthecaseisscheduled.Noopportunitytosafelyexpediteproceduresandtospeedroomturnovershouldbemissed.

Emergencycasesthatareexpectedtoendupintheoperatingroom(lapappy)thatcomeinaftermidnightshouldbediscussedasapwiththeattendingsothata0600O.R.slotcanbenegotiatedwithanesthesia.Thisiscriticalinavoiding‘bumping’ofelectivecasesandmaybestutilizeanover-extendedO.R.staff.O.R.‘CARDS’mustbefilledoutandplacedonanesthesiaofficeandaCPTcodeMUSTbeadded!(doesn’thavetobeexact/enoughtogetcasepulled…)

H&Psarevalidfor30calendardayspriortoanoperation;ifthepatienthasbeenaninpatient(especiallyonanotherservice),pleasebesuretheH&Piswithin30daysand/orhasanaddendumtoupdateit.Consentsaregoodfor60calendardayspriortoanoperation.

PleasediscusswitheachGeneralSurgeryAttendingthespecificneedsrequiredintheiMedConsentsinGeneralSurgery.AvoidpaperconsentsunlessclearedtodosobytheAttendingGeneralSurgeon.

1.AresidentfromtheGeneralSurgerySectionmustbepresentintheoperatingroomnolaterthan7:30AM.Aresident’slatearrivalcouldresultinthelossofthatresident'sabilitytoperform/assistonthatcase.Theresidentwillassistinpositioningthepatient,insertionofFoleycatheters,andthepreparationoftheoperativefield.Aresidentunpreparedforanelectivecasemayberelegatedtoperforminglessornoneofthecase.

2.Allsurgicalpatients(inpatientandoutpatient)shouldhaveabriefoperativenotecompletedelectronicallyinCPRSimmediatelyfollowingtheoperation.Thismustbecompletedpriortothepatientmovingtothenextcarelocation.ThisnotemaybewritteninthePACUiftheresidentorattendingsurgeoniscontinuousattendancewiththepatientduringtransportfromtheORtothePACU.ThisisatemplatednotethatcanbefoundbyselectingtheNotestabandwriting“BriefOperativeNote”inthemenubox.Itistheresponsibilityof

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theoperatingresidenttocompletethisnoteandidentifyasanadditionalcosignertheAttendingGeneralSurgeonofrecordforthecase.Thebriefoperativenoteshouldbeascompleteaspossibleasitisthesoledocumentationoftheoperativeprocedureforthefirst24hrsfollowingsurgeryandcangreatlyassistinpostoperativecare/coordination.Itisrecommendedthatresidentsaddanaddendumtothebriefoperativenotedocumentingthedictationoftheprocedure.

3.OperativeNotesshouldbedictatedbythesurgeryresidentimmediatelyfollowingtheprocedure.Dictationisrequiredpriortothecloseofthatday.MarktheDictationSTAT6ONTHEKEYPAD!

4.Allinpatientsurgicalpatientsshouldhavedelayedtransferordersenteredimmediatelyfollowingtheoperation.Thisdutyisusuallytherequirementofthesurgicalresidentwhoperformed/assistedonthecaseinordertoinsureappropriatecontinuity.

5.OutpatientsurgicalproceduresrequireASUPostoperativeordersaswellasDischargeInstructions.PleaserefertoII.D.

6.Followingeachcasetheoperativeresidentshouldconfirmwiththeattendingthatwillberesponsiblefortheaboveitems,e.g.briefoperativenote,orders,dischargeinstructions,dictationandaddressingthepatient’sfamily.Itisappropriateto‘divideandconquer’thesedutieswithyourattending.

G. CONSULTATION SERVICE

AllconsultationstotheGeneralSurgerySectionfromtheEmergencyDepartment,orInpatientService,shouldbeseenassoonaspossiblebytheresponsibleresidentandtheChiefResident/PGYIV.TheChiefResident/PGYIVshouldpresenttheirplantotheAttendingGeneralSurgeononcall.Onnightsorweekends,thePGYIImaysubstitutefortheChiefResident/PGYIVasassigned.IftheChiefResident/PGYIVisnotavailableduetoleaveorothercircumstance,theresponsibleresidentshoulddiscusstheirassessmentandplanwiththeAttendingGeneralSurgeononcall.Attheveryleast,abriefnoteistobewrittenassoonaspossibleafterseeingthepatientandmakingtheplan.JuniorresidentwilldiscusstheconsultwiththechiefresidentASAP,includinggoingintotheoperatingroom.Onoccasion(notthenorm),dependingonresidentandattendingavailability,andtimeofday(withaviewtoconsiderationofoperatingroomavailabilityorIRavailability),ajuniorresidentmaystaffaconsultwiththeattendingwithoutgoingthroughthechiefresident.

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Everyeffortwillbemadetokeepthechiefresidentintheloop.Alsonotethat,onoccasion,attendingswillbenotifiedofconsultsdirectlyfromotherattendings.

AllhospitalizedconsultpatientsmustbefolloweduntildischargedoruntilresolutionoftheirGeneralSurgeryproblem.Ifappropriate,follow-upcanbearrangedintheGeneralSurgeryclinic.Remember,thereareno"curbsideconsults.”Ifyouarerequestedtoseeapatient,aformalconsultmustbecompletedanddiscussedwiththeAttendingGeneralSurgeononcall.YoumayneedtoprovideafriendlyremindertotheconsultingservicetoplacetheconsultintoCPRSsothatitcanbeappropriatelycompleted.Youmayalsoneedtoentertheconsultorderyourselftoexpeditedocumentationofyourassessmentandplaninthechart.AlsoremindconsultantsaboutNPOandanticoagulationstatus.Withtheexceptionof“necrotizingsofttissue”infections,we,ingeneral,donotseeurgent/emergentforearm,wrist,hand,foot,orheadandneckinfections.Sincewehaveclinicdaily,non-urgentconsultsshouldinsteadbereferredtothenextavailableclinicslotasap.

AttheNMVAHCS,providersaskingforaconsultmusthaveanappropriatequestionforgeneralsurgerytoanswer,whetherprovidertopatientorviae-consult:

BILIARYNOTE:Anybiliarysystemconsultneedsa‘biliarynote’withinonehour!

***Intra-facilitypatienttransferscannotbeacceptedbyresidents.Ifyoureceiveanoutsidecall(oracallfromourVAAOD)requestingapatienttransfer,notifythecallerthatyouasaresidentarenotallowedtoaccepttransfersandhavethemnotifytheAdministratoronDuty(AOD.)Donotengageinanyconversation/opinion

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asthismaybemisconstruedasan‘acceptance.’InsistthecallertalkwiththeAODorGeneralSurgeonon-calldirectly.***

LANGUAGE/NARRATIVES

PleasetrytoincorporaterecentdevelopmentsinlanguageandtechnologyinconsultsandprogressnotesandHandP’s.Specifically,needtostartusing‘performancestatus’forcancersandtumorboardconsults;use‘ENDOFLIFE’and‘palliativecare’wordswhentalkingwithpatientswithseverelylimitedlifeexpectancy;usetheACSsurgeryriskcalculatorasmuchaspossible(especiallyforMandM);useMETS>4inHandP’stodocumentexercisetolerance.

H. GENERAL SURGERY CLINIC

YoursupervisingattendingforaclinicpatientmustbeanAttendingGeneralSurgeonwhoisphysicallypresentintheclinicwithyou.EverypatientevaluatedintheclinicmustbediscussedwithanAttendingGeneralSurgeon.AllnewpatientconsultationsmustbeseenbyanAttendingGeneralSurgeon.DiscussionofthetreatmentplanshouldbedirectedtotheappropriateAttendingGeneralSurgeon.Becauseofthelargenumberofpatientsthatareaccommodatedeachweek,theseclinicevaluationsmustproceedexpeditiouslyandefficiently.Examinationsmustbedirectedtothereferralproblem.Clinicnotesshouldbebrief,withemphasisonpertinentfindings,anyintervalchangesinthepatient’sstatus,therapeuticregimen,andplansforfurtherfollow-up.

Finally,manypatientsorotherfamilymemberswillcallwithquestionsregardingtheircare,wounds,orotherproblems.Ifyouareaskedbythenursingorphysicianstafftoreturnacall,pleasecallthepatient/familybackanddiscusstheproblemorsituation.Don’thesitatetocontactanAttendingGeneralSurgeonifyouhavequestions.

I. WEEKLY CONFERENCES FOR RESIDENTS

ResidentsrotatingontheGeneralSurgeryServiceattheVAwillattendtheVAMorbidityandMortalityConference,heldat7:00AMonthe2ndand4thTuesdaysinthePerformanceImprovementConferenceRoomonthe4thfloornexttotheDirector’sSuite.ResidentsmaypresentcaseswhenGeneralSurgeryis‘up’forpresentation.

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TumorBoardisheldweeklyat12:30PM,Tuesday,inPathology.ThePGYIIlevelresidentisexpectedtoprepareandpresentthepatientsontheTumorBoardSchedule.AcopyofthisscheduleisdistributedtotheResidentOfficeandtoMs.SauveontheprecedingFriday

GeneralSurgeryIndications/Educational(Preoperative)Conferenceisheldweeklyat7:00AM,Thursday,inthe3B-125ConferenceRoom.Theseniorresidentonserviceisexpectedtoprepareandpresentthepatientsontheoperativeschedulefortheweekthatstarts10daysfromtheThursdayconference.Itisexpectedthatthecasewillbecompletelypreparedforpresentationtoincludeallpertinentstudies.

GeneralSurgeryPathologyConferenceisheldweeklyat7:30AM,Thursday,inPathology

GeneralSurgeryAttending/TeachingRoundsareheldweeklyatnoon,Friday,startingin3B-SICU.Themedicalstudentsorinternsareexpectedtoprepareandpresenttheirownpatientsalongwithpertinenteducationaltopics.Alternatively,wecanusesomeofthistimetogooverquestionspertinenttotheSurgeryIn-Serviceexam,e.g.SESAP,dependingontheChiefResident’sinterest.

J . DUTY HOURS

Dr.Ketteleristheon-siteGeneralandVascularSurgeryResidentCoordinatorattheVAforadministrativeissuesrelatedtoyourrotationattheVA.Allrequestsfortimeoff(vacations,timeawaytointerview,familyemergencies,etc.)shouldbecoordinatedthroughher.(Dr.Vigilinherabsence.)

AllsurgicaltraineeswhorotateontheservicearerequiredtoplacetheirdutyhoursintoNewInnovationsnolaterthantheclose of business each Monday for the preceding week.Weinsistuponaccurate and honest dutyhourdocumentationsowecaneffectivelyassessrotationobligationsandbeabletomakeadjustmentsandchangesappropriatefordutyhourrequirementsandtoavoidfatigueandexhaustion.Additionally,ifyouoranothersurgicaltraineeontheserviceisapproachingthedutyhourlimitsasprescribedbytheGeneralSurgeryProgramDirector,pleasenotifyDr.KettelerimmediatelysothatcorrectiveactioncanbetakenIfthereareanyquestionsaboutworkhours,pleasedirectthemtoDr.Ketteler(Dr.Vigilinherabsence).

K. CALL RESPONSIBILITIES

WEEKDAY NIGHTHOME-CALL:DuetoPGY1residentsbeingunabletoparticipateinnightcallbeginningJuly2011,theVAhomecallscheduleduringtheweeknightsisarotatingcross-coveragescheduleamong:thePGY4onVascular,thePGY2onENDO,thePGY4/5onGeneral,andthePGY2onGeneral.ThisschedulewasdecideduponinAugust2011inajointVAresident/facultycommitteemeeting(initiatedbyDr.Nelson,thentheUNMSurgeryProgramResidentProgramDirector).Inthismeeting,homecallwasdeemededucationalbyboththeresidentsandthefaculty---buttheeveryothernightcallasseparateserviceswascreatingfatigue

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andexhaustion,evenifnotviolatingdutyhours.Thus,arotatingcallschedulewasinitiatedinSeptember2011.Thisschedulewilltrytoassignresidentstoasinglenightofcross-coveragecallMondaythruThursday.Theweeknightswillattempttobechosensothatiftheresidentisupallnight(orisfatiguedorexhausted),theresidentcanbesenthomethenextmorningwithoutmissingcasesand/oreducationalopportunities.

Knowingtheabove,thegeneralandvascularcross-coveragehome-callseniorresidentscheduleisasfollows(assumingafullresidentcomplement):

MondayandWednesdaynights:GeneralSurgPGY4/5orGeneralSurgPGY2

Tuesdaynights:VascularSurgPGY4

Thursdaynights:EndoPGY2resident

Eachservice’sPGY1(orPA/NP/seniorresident)willholdtheirindividualservicepagers(Gen=251-0120,Vasc=251-0808)from0630until2000.Eachserviceisresponsiblefortheirownservices’obligationsfrom0630thru2000viathe251-pagersunlesspropercheck-outhasoccurred(seebelow.)

Theseniorhome-callresidentmaybegintakingcross-coveragefortheotherserviceat1500----withapropercheckoutfromtheotherservice.[Theseniorhome-callresidentisnotrequiredtotakecross-coveragefortheotherserviceiftheotherserviceisstillattheVAin-houseseeingconsults,operating,rounding,etc.]However,from 2000 to 0630,theassignedseniorhome-callresidentwillbegingeneral and vascular cross-coverage via his/her individual UNM resident pager number .(ThisavoidstheseniorresidenthavingtoreturntotheVAtogettheservice251-pagerifhe/shewasabletoleavepriorto2000.)**TheVAcall-schedulethrutheoperatorissettoreflecttheabovepagerassignmentsandanychangesneededinthecallscheduleneedtobeapprovedbyDr.Ketteleratleast3daysinadvance(Dr.VigilinDr.Ketteler’sabsence).**

DuringFridaymorningUNMmandatoryeducationalconferences,theGenSurgeryNPwilltakeprimarycallfrom0700-1100andtheVascularSurgeryPAwilltakeprimarycallfrom0600-1100.Residentswillresumeresponsibilityforservicecallsat 1100.(ResidentsareexpectedtofindeachNP/PA/Attdtogivethemthepager).

Weekend-CALL:Tworesidentswillbeon-call(preferablyoneseniorresidentfromeachservice)forFridayat2000thruMondayat0630.Theresidentscandecidetosplitthecallseachnightorsharethecallseachnight.Bothresidentsareexpectedtoroundeachday---unlesstherearepriornight/daydutyhourconcerns.Thegoalsforweekendcallarethesameasforweekdaycall:to avoid fatigue, exhaustion,

34

and duty hour violations.Thus,theweekendcallresidentsneedtobeinclosecontactandcommunicationwitheachotherandalsowiththeweekendfacultytoavoidhourissuessoappropriatecoverage(evenviathefaculty)canbeanticipatedandarranged.

Reviewing the above brings these thoughts to mind:

· Maintenanceofcontinuityofcareisparamountforourpatients.

· Avoidingunnecessarycallsand/orreturnstothehospitalatnightareparamountforourresidents

§ Expectedtopro-activelycallat2100towards,ICU

§ Residentsareencouragedtocontactfacultyduringthenightforquestionablerequestsandconsults(priortoreturningtoVAtoseesuch)

· Meticulouscommunicationandcheck-outbetweenfaculty,residents,andwardproviders(RN,LPN,HT,MSA,NP,PA)isvitaltomakethesystemworksafelyandeffectivelyforourpatientsandourresidents!

III: WEEKLY SCHEDULE

Monday Tuesday Wednesday Thursday Friday

PGY I

am

7:30am

Operating Room

or

9:00am Minor

Procedure Room

7:00amVA M&M 2ndand4thTuesdays

8:00amto11:30am

CLINIC

7:30am

Operating Room

or

8:00amto11:30am

CLINIC

7:00am

VA Indications, Education, & Pathology

Conferences

3B-125

7:00am

UNM Grand Rounds, M&M &

Resident Education

Conference

pm

1:00pm-3:30pm

CLINIC

12:30pmto1:30pmTumor Board

1:00pm-3:30pm

CLINIC

NOON

General Surgery Attending/Teachi

ng Rounds

35

PGY II

am

7:30am

Operating Room

ENDOSCOPY-all day

Vigil/VB/Ford in am Lopez/Last in

pm

7:30am

Operating Room

or

8:00amto11:30am

CLINIC

7:00am

VA Indications & Pathology Conferences

afternoonENDOSCOPY

Dr . Kingsley

7:00am


Resident Education

Conference

pm

Operating Room

or

1:00pm-3:30pm

CLINIC

12:30pmto1:30pmTumor Board

Operating Room

Operating Room

or

1:00pm-3:30pm

CLINIC

NOON


ng Rounds

PGY V

am

7:30am

Operating Room

7:00amVA M&M 2ndand4thTuesdays

8:00amto11:30am

CLINIC

7:30am

Operating Room

or

8:00amto11:30am

CLINIC

7:30am

Operating Room

7:00am


Resident Education

Conference

pm Operating Room

12:30pmto1:30pmTumor Board(whenpossible)

NOON


ng Rounds

IV. ATTENDING SPECIFIC INFORMATION

A. FORD

B. KINGSLEY

1. Dr.Kingsleypreferstodoherownbriefoperativenotes,ordersanddischargeinstructions,justaskherattheendofeachcase.

2. Dr.KingsleypreferstouseSQHeparinforDVTprophylaxisinsteadofLovenox.

C. LAST

Dr.Lastpreferstodohisownbriefoperativenotes;Hewilloftendothepostoporders.(Thiswillagreeduponattheendofthecase.)HepreferstouseSQHeparinforDVTprophylaxisinsteadofLovenox.Analcasesaregiven10ozMagcitratedandclearstheeveningbeforesurgeryandafleetsenemax2intheamathomeandorintheASU.Golytelybowelprepsaredoneforcolon.AlmivopamoncalltoORandpostopforelectivecolonresections.HassancutdownforlaparoscopicaccessandroutineIOConallgallbladdercases.RepeatclosereviewofCTjustbeforebowelcases(*know where the ureters are expected to be and what will be the window in which we access the abdomen).InguinalherniasgetUA’spreop.FoleyCathetersarefrequentlyusedandorderstoD/Cmustbewrittenwithadditionalorderstopreventurinaryretentionepisodes.

D. LOPEZ

37

E. VIGIL: fleetsenemax2inasuforanalcases.Golytely,neomycinandflagylbowelprepforcolon.SQHepforDVTprophylaxis.RoutineIOC.

Ingeneral,doesnotget‘routine’postoplabs.Shouldhaveareasonforeverylab.

Almivopamforcolonresections.

SchedulepostopclinicappointmentfromclinicvisitratherthanfromASUorders.

InguinalherniasgetUA’spreop.

Laptepsneedbotharmstucked.Lappy’sdon’tneedarmstucked.

Doesnotdoforearm/hand/wrist/feetIandD’s.

Portacathsnotseenpostop>gotoHem/Onc

Pleaseseefeedingtubepolicyinourownconsultrequestform

F. VALDEZ-BOYLE

38

V. CONTACT INFORMATION

QuestionsorcommentsregardingthismanualoranyothersectionissuesshouldbedirectedtotheGeneralSurgeryAttendingStaff.

Juliet Lopez MD

Office: 505-265-1711 ext

Pager:251-0417

PersonalCell/Text:967-8212

Email: [email protected]

Stuar t Ford MD

AttendingSurgeon,GeneralSurgerySection

Office:505-265-1711ext2171

Pager:505-251-0627

PersonalCell/Text:975-7489

Email:[email protected]

Darra Kingsley MD

AssociateChiefofStaffforEducation


Office:505-265-1711ext.2989

Pager:505-951-1603(novoicemail)


Rueben Last MD


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Office:(505)265-1711ext5430

Pager:505-247-5444

PersonalCell:6158878


Lorene Valdez-Boyle MD


ColorectalSpecialist

Office(505)265-1711ext4810

Pager:na

PersonalCell:850-2020


Anthony Vigil MD

Chief, General Surgery Section


Office505-265-1711ext4165

Pager:505-251-0647

Cell:975-7449


Stacey Schneider RN

NurseManager

Office:505-265-1711ext5867

Cell:505870-5983

Pager:505-251-0062


40

JaniceSchwartzRN

CancerCoordinator

Office:505-265-1711ext2523

Cell:505-259-4129


On Call General Surgery Resident Pager

(505)251-0120

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Blood Transfusion Guidelines

As noted above in discharge section, the attending must be notified if r esident is consider ing giving blood products!

TYPE AND CROSS ONLY FOR CASES WHERE YOU ARE SURE TO USE THE PRODUCTS. T & S FOR CASES WHERE NO ONE

WOULD BE SURPRISED IF BLOOD WERE GIVEN.

If you or nurse thinks there is a transfusion reaction, immediately stop the tr ansfusion, call blood bank and Call Dr . Vigil and wr ite a note!

Platelets

RBCS

RBCsmaybeindicated

Hemoglobin<7g/dlinpatients

• Stable non-bleeding patients with no clinical symptoms attributable to anemia • On a ventilator • With stable cardiovascular disease • Who are postoperative (higher hemoglobin if risk of end-organ ischemia)


• With acute hemorrhage (>/= 30% TBV) & hemodynamic instability or inadequate O2 delivery • With acute myocardial infarction, ST changes on EKG, and/or unstable angina

• Apheresisplateletunits(1unitequivalentto~6pooledwholeblood-derivedplateletunits)

• Prophylactictransfusionwhenplateletcount<5,000–10,000/μL(spontaneousbleedingdoesnotoccuruntilplateletcountfallsbelow5,000–10,000/μL)

• Plateletcount<50,000/μLinableedingpatient • Plateletcount<50,000/μlinpatientundergoingmajorsurgeryorinvasive

procedures,includingliverandtransbronchialbiopsy.Plateletcountsbetween30,000and50,000/μLaregenerallyadequateforhemostasis;

• Plateletcount<100,000/μlinapatientundergoingneurologicorophthalmologicsurgeries/procedures

42


• With symptoms attributable to anemia (e.g., tachycardia, dyspnea, hypotension, altered mental status) RBCsarealmostneverindicatedwhen

• Hemoglobin is > 10 • Do Not Transfuse based solely on Hemoglobin trigger. Transfuse based on patient’s intravascular volume status,

evidence of shock, acuity of anemia & cardiopulmonary physiologic parameter • In the absence of acute hemorrhage, transfuse RBCs in single unit increments followed by clinical laboratory

assessment

PlasmaTransfusionGuidelines–Adults

Clinicalpracticeguidelinesandrecommendationsarenotconsideredtobestandardsorabsoluterequirements.Theydonotapplytoallindividualtransfusiondecisions.Clinicaljudgmentiscriticalinthedecisiontotransfuse;therefore,plasmatransfusionaboveorbelowthespecifiedINRthresholdmaybedictatedbytheclinicalcontext

Patientwithactivebleedingorpre-invasiveprocedure

INR>2.0

Foremergentwarfarinreversal:recommendvitaminKandfour-factorprothrombincomplexconcentrates(PCC)(e.g.,KCentra)asfirst-linetreatment.

CNS/spinaltrauma,CNS/spinalsurgery,oculartrauma/surgery,CNShemorrhage,orinvasiveneurologicprocedure

INR>1.5

Inheriteddeficiencyofsingleclottingfactors(factorsII,V,X,XI,andXIII)

Ifspecificfactorisnotavailableinconcentrateform.Plasmatobegivenforactivebleedingorinpreparationforinvasiveprocedure/surgery.

ThromboticThrombocytopenicPurpura(TTP)

Duringplasmaexchange.Canalsobeusedforsimpletransfusioninthesepatientswhileawaitingvascularaccessforplasmaexchange.

HemorrhageProtocol/Massive Giveatleast1Plasmaforevery3RBCs.Referto

43

TransfusionProtocol institutionspecificprotocols.

Replacementfluidintherapeuticplasmapheresis

Maybeusedifthepatientishypofibrinogenemicorcoagulopathic

Contraindications • For bleeding in the absence of clotting factor deficiencies.

• For supratherapeutic INR due to warfarin without bleeding or without an imminent invasive procedure

• For replacement of immunoglobulin in patients with immunoglobulin deficiency.

• For patients with one or more coagulation factor deficiencies who are not bleeding and who are not anticipating an invasive procedure.

• As a volume expander. • As a nutritional supplement.

References

1. Guyatt Gordon H et al for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis: Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest.2012;141(2)(suppl):7S-47S.

2. Circular of Information for the Use of Human Blood and Blood Components, FDA, current edition

RESIDENTS’ CODES FOR VA

**ResidentscomingTOtheVA

Besureyourcomputercodesarereadytogothedayyoustart!(Thisisaprofessionalismissue.)CallJerryCasteelat265-1711ext.4946stat!

**ResidentsLEAVINGtheVA):

44

1)youarerequiredtocompleteallyourCPRSalertspriortoleavingtheVA

AND

2)whenyouleavetheVAyoumustassigntheresidenttakingyourroletobeyourSURROGATEforfuturealertsinCPRS

ForquestionsregardinghowtodosuchpleaseseeDr.KettelerorDr.Vigil.

Residents CPRS

QUICK REFERENCE GUIDE

New Mexico VA Health Care System

Log-on to the Network

1. Press and hold, Control, Alt keys + and press Delete key. 2. Type your Network User Name (vhaabq_ _ _ _ _ _) 3. Press Tab key (or use the mouse to move to the cursor to the password field). 4. Type in your Network Password 5. Press the Enter key or Click OK. Log-on to CPRS 1. Double- click the CPRS icon. 2. Type in your Access Code. 3. Press the Tab key. 4. Type in your Verify Code. 5. Press the Enter key.

Patient Selection

45

After you sign in to CPRS, the Patient Selection screen appears that enables you to choose which patient record you want to open and process notifications you have received. - To select a patient, type their name or social security number. (You can also use the mouse to select a clinic, ward, or specialty and then click on the patient's name.) - When you click a patient name, CPRS brings up the demographic information under the OK and Cancel buttons so that you can verify that you have selected the correct patient. - Click OK.

The Cover Sheet

The Cover Sheet is the first screen you see after opening a patient record. It summarizes important information about the patient, such as current orders, recent lab tests, medications, demographic information, and so on. Click on any item to get more detailed information. The CPRS Windows interface mimics the paper chart of a patient's record. To go to a different part of the patient chart, Click on the appropriate tab at the bottom of the chart. For example, click on the NOTES TAB to read or write a progress note.

Selecting Multiple Orders for Processing on the Same Patient To select non-consecutive orders, press and hold the “Control” key and left-click on the desired orders. To select a block set of orders, press and hold the “Shift” key left-click on the first order, then the last order you wish to select.

Changing the Orders View To change the view of the orders: The user may select “Active”, “Expiring” or “Unsigned” by selecting “View” on the toolbar. For a more specific view of the orders: - Select “View” on the toolbar. - Select “Custom Order List”. - Select Service – from all to individual. - Select Status – from all to specific You can create a custom order list for the selected patient. (With this command, you can quickly sort the orders list to isolate specific types of orders by choosing the necessary criteria.

Create a Custom Order List 1. Under the Orders tab, change your view. 2. Under the View menu choose Custom Order List… 3. In the Custom Order View dialog, click the desired grouper or individual service. 4. Click the desired type of order. 5. If desired, set a date range:

a. Click the box in front of Only List Orders Placed During the Time Period b. Enter the beginning date in the From field c. Enter the ending date for the custom view in the Through field

6. Choose whether you want the entries in reverse chronological sequence. 7. Choose whether you want the orders grouped by service. 8. Click OK. After you customize your view of the orders list, you can save the view as your default view. You will then see that default view when you go to the Orders tab. You can still change the view or make a custom order list, but you will have the default view. You can save any view of the orders list as a default view.

Time Delay Orders for Admissions/Transfers 1. Write Delayed Orders button.

46

2. Pick the event that will release the orders – ie. Medical ICU Admit for M ICU pts or Medicine Ward Admit for Ward or Tele pts; Trans Care Unit ward transfer for ward pts. 3. Enter transfer information. Specify Attending Doc & Primary Care Giver & Dx click OK 4. Highlight orders to copy. Click OK 5. Add new orders using Medicine Order Sets 6. Sign the orders then click active orders again

View an Order 1. Double click on any order for detailed display. 2. To sort by status/service click View menu on orders tab

Discontinuing Order

1. Select the Orders tab.. 2. Select the order or orders you want to discontinue 3. Select Action | Discontinue/Cancel. 4. Select the name of the clinician (you may need to scroll through the list), select the encounter location, and then select OK. 5. Select the appropriate reason from the box in the lower left of the dialog and select OK. 6. If the order you are discontinuing is a pending renewal of another order, CPRS needs to know how to deal with the order you are discontinuing, and the original order. Choose the appropriate action from the dialog that displays: o DC Both, o DC Pending, and o Cancel – No Action Taken

Write a New Progress Note

1. On the Notes tab, click New Note. 2. In the Progress Note Properties dialog, select the following: a. Progress Note Title (e.g., Nursing Note, Monthly Summary, etc. Note titles are designated by your Clinical Center b. If necessary, change the note date by clicking the button next to the date and entering a new date. c. Click OK. 3. In the main text box, type in your note and /or insert predefined text from desired templates. Note: Spell checking and grammar checking are available in the CPRS GUI.

Using Templates 1. Click the Templates drawer. 2. Locate the template you need. 3. Double-click the template, drag-and-drop the template into the document, or right-click and select Insert Template. (It will be placed where the cursor is.) Signing Your Note 1. Select Action | Sign Note Now (or Sign Discharge Summary Now). 2. To sign orders or documents and stay in this patient record, select File | Review / Sign

47

Changes.... 3. To sign and move on to another patient, choose File | Select New Patient 4. In the dialog that appears, enter your electronic signature code. 5. Click OK.

Adding an Addendum to Progress Notes CPRS enables you to make addenda to Progress Notes. 1. Click the Notes tab. 2. From the index of Progress Notes on the left of the dialog, click the Note to which you want to add an addendum. 3. Select Action | Make Addendum. 4. Enter the text of the addendum. 5. Select the Action menu and choose Sign “Note Now”. You can create multiple addenda to a single Progress Note if you choose and identify additional signers.

Identifying Additional Signers 1. After you have signed the note, select Action | Identify Additional Signers. 2. To identify a signer, locate the person's name (scroll or type in the first few letters of the last name) and click it. 3. Repeat step 2 as needed. 4. (Optional) To remove a name, click the name under Current Additional Signers and click Remove. 5. When finished, click OK.

Completion of an Unsigned Note You can process your unsigned notes from the alert dialog box when you sign onto CPRS GUI. If you remove an alert for an unsigned note and you do not remember the patient's name, you can look up "ALL MY UNSIGNED progress notes" in VISTA TIU menu. If you know the patient's name you can go to the notes tab. - Select “View” from toolbar. - Select “Unsigned Notes”. - Select appropriate note. - Select “Edit” from toolbar. - Select “Edit Progress Note”. - Make edits as appropriate.

Viewing Progress Notes By selecting “View” the user may view: - Signed Notes (All) - Signed Notes by Author - Signed Notes by Date Range - Uncosigned Notes - Unsigned Notes - Custom View

Finding Specific Text in a Note If you want to find results of a prostate exam search "prostate" or "DRE" using the Search for Text function on the Notes Tab. 1. Right click on all signed notes will give you the option for “Search text”. 2. Select the “Search for text (within current view) 3. To find the results of a prostate exam search “prostate” or “DRE” using the Search for Text.

48

4. Select Ok. Note: the “Search for Text” can also be found on the View Menu”.

Progress Note Entered In Error If you enter a Progress Note in error or on the wrong patient and it has already been signed, by NMVAHCS Medical Policy, this note will be retracted and will not be available for clinician viewing. Guidance on what to do if you have signed the progress note on the wrong patient: 1. First make an addendum to the note stating that the note was "Entered in Error" and electronically sign

the progress note. 2. Next, identify either "Martines, Rebecca" or “Janel Sams” as an Additional Signer of the note. Once one

of them is identified they will retract the progress note once they receive the view alerts. Notifications and Alerts

Notifications are messages that provide information or prompt you to act on a clinical event. Clinical events, such as a critical lab value or a change in orders trigger a notification to be sent to all recipients identified by the triggering package. “Notifications” are located on the lower third of the screen. The user has the choice of: - “Process Info”. - “Process All” – If selected the user may move from one notification to another beginning with the first listed. - “Process Selected” – If selected the user may process just the notification selected. The user will be given the choice to continue through the remainder of the notifications if desired. - Reason for notification with opportunity to act on “action” notifications and to view “information” notifications. - “Next” - To proceed to the next notification.

Surrogate Settings 1. Click on the Menu Bar and select “Tools” 2. Go to the “Options” menu and select 3. Click on the “Notification” Tab 4. Select the “Surrogate Settings” 5. Choose a Surrogate from the drop down bar. 6. Click the “Surrogate Date Range” to specify a specific date Range.

Reports Cumulative and All Tests by Date

Can be sorted by heading and/or date range

Available Reports 1. Click on any of the available reports 2. Click on + to expand tree view 3. Click on Selected Date Range (if available).

Adhoc Report A patient at a site can have multiple procedures performed. Over a certain period of time, this would make it difficult for the physician to search through the Clinical Reports for Medicine/CP Reports in CPRS. The site can setup an Ad Hoc Health Summary component for a specific procedure. This way, the physician can just look through the reports for a specific procedure. 1. Go to the reports tab 2. Click on + Health Summary to Expand tree View 3. Click on Adhoc Report

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Find the Health Summary component that you want and select it. Enter the Occurrence Limit and Time Limit that you want. Once you clicked the “OK” button, you should generate only the reports found for that occurrence and time limit.

Imaging 1. Click on a specific image on the list View as directed in Notes section. 2. Click on Tools Menu, Imaging to view images

VistAWeb To access VistAWeb, you must first log into CPRS using your access/verify codes, select a patient, and select VistAWeb from the Tools menu. VistAWeb will maintain context with the selected patient and retrieve data for that patient from all sites where the patient has records. When you select a different patient from the CPRS File menu, VistAWeb will maintain context with the new selection. 1. Click on VistAWeb (top left) when Blue 2. Your Internet Explore will open a new window 3. The patient’s name, SSN, and DOB will be viewed in the new window 4. You will be asked to “Proceed” or “Cancel”

CPRS HELP Whenever you need more information about anything in CPRS, click on Help on the menu bar at the top of

the Window, and choose Contents.

CAC Support for CPRS GUI

Daily CPRS Issues – Call Ext. 2490

Any new or changes to existing templates, consults, or progress notes, see your service ADPAC to submit a project request form

TIME OUTS MUST BE RECORDED BY RN PRIOR TO ANY

INVASIVE PROCEDURE WHERIN AN INFORMED CONSENT WAS OBTAINED.

PROCEDURE VERIFICATION PROCEDURE

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HowtochartatelephonenoteforGeneralSurgeryscopes:

ClickonNEWVISIT

VisitlocationABQGENSURG/TELEPHONE-X

53

Documentyournote,andthenencounter:

Selectnotetitle

GENERALSURGERYTELEPHONENOTE

Markserviceconnectionandyournameastheprovider

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Diagnosistab

Preoporpostopcall

55

Codefortheamountoftimeyouspentonthephone

Proceduretab

Youdidit!Yeah!

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