Admitting to Medicine: Once you have decided to admit a patient to the medical service, you must page the Senior Medical Resident (SMR)(#8-0636) and speak to him or her about the patient either over the phone or in person. After telling them you have an admission, give the name and MRN and a brief summary as to why the patient is being admitted. Afterwards, you must write a brief patient summary and “Z” the patient out on Quadramed. On your paper chart, you must write the admitting diagnosis, service (Medicine) and bed type (ICU, CCU, MSOU, Telemetry, or Floor). Remember that most chest pain patients go to Telemetry when they are first admitted. You also must get the attendings signature on the chart.
Admitting to Other Services: The same procedure follows to admit to other services, with the exception that the SMR is not called. Instead you should have already spoken with the consultant about the admission. (but you still need to Z out the patient)
Discharging a Patient: When you discharge a patient, you will have to click the discharge tab under the patient’s name on Quadramed and write a brief discharge summary (2-3 sentences will do) as well as indicate what kind of follow up they will require. On the “Discharge Prescriptions” tab, you must also enter any prescriptions that the patient will need and have the attending sign both the prescriptions and the chart. The zone nurse usually discharges the patient, however if you decide to do it your self you should verbally provide all discharge instructions to your patient and ensure that they understand before having them sign.
Follow up information aka “Greensheeting”: Upon discharge, you may indicate that the patient will need to be followed up by the NP’s in our follow up office. This may include following up on various culture results, STD testing results, or getting a patient an urgent appointment. “Greensheeting” is actually done on the computer (not on a green sheet of paper anymore). Please ensure that you have the patient’s correct phone number and let them know that they will be contacted by phone.
Kathy L. Chuang, MD 2011 (modified by @em_stevemcguire)