The Department of Surgery

Phase II Surgery Clerkship

Patient Care Responsibilities

Clerkship Overview
Clerkship Goals
Clerkship Objectives
Patient Care Responsibilities
Operating Room Conduct
Feedback
Elective Cases
VA Hospital Schedules
Lecture Schedules
Call Schedules
Association for Surgical Education
Knot Tying, Suturing

Patients
  1. During your Surgical Rotation, you will have close daily contact with patients and their families. You will be learning medical facts and developing problem solving skills as well as developing equally important interpersonal skills in terms of the physician-patient and physician-family relationship. Although it may sound trite, please remember that patients are sick, and their families worried. Think about what you're going to say before you say it.

  2. Always discuss up-coming issues regarding diagnosis, prognosis, or management with your housestaff and attending before talking with patients and family.

For each patient you admit
  1. Perform a complete history and physical examination on select patients on the day of admission.

  2. Formulate a complete problem list.

  3. Review the patient's X-rays with housestaff and/or a radiologist.

  4. Review the patient's EKG (if indicated) with housestaff.

  5. Review the patient's laboratory data with housestaff.

Procedure Documentation

Please remember that you must perform procedures on your patients under supervision of someone who knows how to do the procedure before you do any procedure without supervision. You should ask a houseofficer, nurse, faculty physician, or appropriate technician to observe and/or help you with procedures.

Medical Records
  1. Admission History and Physical Examination: For select patients you admit, you must write a complete history and physical, utilizing standard format, followed by a patient-oriented assessment.

  2. Progress notes: Always use SOAP format. You should write daily notes on each patient. The notes should be reviewed, corrected, and signed by your housestaff the day they are written.

Presentations (Rounds/Conferences)
  1. Use Minimal notes. (It is permissible to have a 3x5 card with pertinent lab data.)

  2. Give concise, succinct, well-organized presentations. (Less than 2 minutes)

  3. The following is a standard acceptable form to use for patient presentations:

    1. Pertinent history: (Always begin with patient's age and chief complaint, followed by HPI, and PMH, ROS only as pertinent.)

    2. Pertinent physical findings.

    3. Lab Data: (blood work, EKG, X-rays, etc.)

    4. Assessment, including differential diagnosis; concise statement of your assessment of patient's problem(s).

    5. Plan for care, including diagnostic and therapeutic interventions.

  4. Prepare in advance for your presentation for rounds (consider practicing the presentation to your intern for fellow student).

  5. Keep up with your patients (symptoms, lab data, and physical findings) and be ready to give a brief summary at any time.

  6. READ in standard textbook of surgery about your patient's disease(s) before rounds.