DIP Episode 235 - How To Admit New Patients Efficiently (For med students and interns/residents)

Okay, welcome. My name is Divine, I'm a resident. This is episode 235 of the Divine Intervention Podcast. And in this podcast, I'm going to be going over how to admit a patient on an internal medicine floor. Okay? This is probably very useful for people that are interns, people that are 30-year-old students going through their IAM or T-shirts. So yeah, so let's just get right into it basically like because admissions, right? You see some people like new 30-years or some residents, you see a new admission ticket them like three or four hours to complete. It really doesn't, to be honest with you, it should probably, you know, I feel like if you're working at a decent pace and if you practice what I tell you to do in this podcast, you can probably complete an admission in like less than an hour, right? From like start to like when you get the call to when the patient is admitted and talked in less than an hour. So let me show you how I basically did this and I mean again, I'm not saying this to be both full or proud. I'm trying to be as humble as possible about this and I've definitely learned a lot of tricks of the trade from people. But many times I could do admissions much quicker than an hour. In some cases and you know, it's just good to be efficient, right? But again, you need to make sure you're accurate. So let's just talk through this process from beginning to end.

So the first thing is, you know, you usually get a call that a new initiative is coming and you know, probably you probably say a little bit like, ah, gotta go with this admission. Well, after you say, you know, kind of keep your head up high and get to work. Right? So the first thing I always do because you see some people the moment they get a call, the first thing you do is to boom. I mean, obviously the patient is on stable. You need to run and go see the patient. But you know, usually the patient is being, you're being called from the emergency room. The patient is usually stable. If the patient is stable, you know, go ahead and go to the medical record. That's the first thing I do. Second thing I do is I pull up some kind of safe documentation system. Either in the medical record itself or like, like something that is safe to document, right? Just make sure it's something you can recover easily and it's something that's not accessible that meets hip-hop quality or whatever. Let me just say that and I'll leave it at that. And then the first thing I do is actually read the emergency department note. Like I read the ED note and the triage note. And the thing is, as I'm reading the ED note and triage note, I'm essentially beginning to fill in sections of my actual notes, right? That's why I say to pull up a note documentation system and beginning to fill out like some basic stuff about the HPI and I'll give you like my order that I document things in, right?

So I'm already literally beginning to fill out stuff about the HPI, the review of systems, the ED course and all that stuff. I'm literally beginning to fill in all that information, right? So I read the ED note very thoroughly, like I'm very detailed with this process. I read it because a good line of information I also read the triage note because essentially right in the triage note, they'll tell you how the patient presented, how EMS found them or whatever, right? So all those things you can very easily write into your note, right? So basically what are you trying to accomplish? You're trying to write it as much of your note as is possible before you see the patient, right? And then the next thing I do is as I write my note, if there's anything that's not clear from the ED note or from the triage note, one thing I try to do is I put like bold letters, bolded letters by things I want to clarify with the patient, right? So let's say the ED notes, like let's say I'm reading this note and it's a person that presented with this, this, this, and then I'm thinking about like CHF exacerbation, right? And I notice that you know the ED did not check for JVD or something, I'll just bold out those things as things I would do. It just, it just makes my visit with the patient a lot more focused and a lot more high yield, right? If you may. So as I'm writing my note, I bold out those things that I'm like, okay, I'd like to clarify with this patient when I actually see them, right?

And one other thing I then go to next is I look at the patient's vitals, right? Just to get an idea of how they presented, right? Like if a patient came in and their blood pressure is 140 over 90, their heart really is like 75, like all their vitals are normal, they're probably fine, it's probably something a little not bad, right? Something that's not going to kill them immediately, all right? And then the next thing I do is I look at the labs and I write on anything that's grossly abnormal. In fact, this is how I make my problem list, right? The way I make my problem list, first thing I do is like the patient's shift complaints, shift presentation, I add that to my problem list, any super abnormal labs, right? So if the appartus seems like, I don't know, like if the sodium is like 134, right? Come on, I'm not going to worry about that, that's not in my problem list, but if the patient's potassium is like 6.5, that's probably important to know, right? So my problem list is made up of the achieved complaint, like what he presented with any super abnormal labs, that's true. Any, any image that has been done, most patients that come to the hospital get imagined, right? Any image that has been done, if there was a diagnosis that was given, I also add that to my problem list. And then the fourth thing I add is I make sure that I look at the apathematical history, just impacting terms of like chronic problems they have.

I also add those to my problem list because it's not like they leave those problems at the door when they get to the hospital, right? Those problems still have to be actively managed in the hospital. And then, so again, like I said, I look at the image and see there's any diagnosis given I add that to my problem list. And then one of the things I also do is I also look up the interventions that have been done in the ED, like did they get fluids? How many liters of fluid did they get? Did they get anti-ematics? Did they get pressers in the ED where they give in benzoes? Where they give in pin control? Where they started an antibiotics? All those things I just like to check. And usually you can find this under the mar. It depends on the kind of medical record you're using, but is usually found in the mar section of like the MER section of most of most electronic medical records, right? And once you find that, right? That will usually give you an idea of the kind of plan you want to enact with with a patient, right? And just as an add-on, I will go ahead and say is if a patient is like super complex, one thing I sometimes do is I just dig up notes from like the most recent admissions. The thing is usually that will help me with organization because the person that wrote the previous note probably like indeed a pretty extensive dig in.

And you know, I try to find a good note where like the catalog, the apaths medical history, the assurgical history, like their presentation, because many times patients will present for something that they've presented with like a while back, right? So you know, I just use that to organize my information, just makes things a lot more succinct, a lot more like a lot quicker, right? And in terms of notes, so to be honest with you, I'm not a big fan of using templates for many things in medicine. I usually freestyle my notes because again, I know this is that some of those templates, they'll pull all these labs and data from like everywhere in the medical record, makes my note all clogged up. So I really don't do that. But I notice it because maybe like, oh, divine, you must be wasting a lot of time then. No, I don't waste a lot of time. Again, I put the things that I know are pregnant and will help you and will help the hospital bill and bill appropriately. I don't, but I don't waste time with fluff like laps from this, from that, from this, from that, all the normal abnormal, everything in one spot. I don't do any of that garbage. So I don't do that. So I freestyle most of my notes, right? So my HP, right? So again, I'll put in my HP. I like, and again, I don't put fluff, right? Mr X is a 55 year old male with a pass medical issue, blah, blah, blah, blah, blah, presenting on the chip complaint of this, right?

And then you know, you've gone through 30 year or you've heard of old cards or whatever, you know, you kind of put in those old cards questions. And I'm, again, I'm very matter of fact on that. I put in my old cards questions and then I put like the, the, any like other pregnant things. And then I usually throw in a sentence for like review of systems. I say, Mr. This endorses blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah. And when I'm putting that first sentence, so let's say they have a pass medical issue of like diabetes. I always put the last chemical, you won't see. Or let's say they have, they have a pass medical history of a heart failure. I put the most recent ejection fraction. And I try to put dates on things, right? Or they have a history of HIV. I try to put the most recent on CD4 count. That's really helpful. Right? So I do my HPI, again, my HPI is really pretty short. All I answer is this is the person's age. This is the a pass medical history. This is their, with a pass medical history of blah, blah, blah, blah, blah, uh, presenting on the chip complaint of blah, blah, blah, blah, blah. He symptoms began so, so, so, so on. So time look at it. We're again, the old cards questions. Um, and then again, anything that's pregnant, right? So let's say this person is coming over to see what the exacerbation, you know, I want to throw in like that he still smokes or something like that, right?

Or if he has been hospitalized for something similar in the past, like I'll throw that into my note, right? And then I'll usually, after I put my HPI, the next thing I do is I put a short section on what I call ED course, right? ED course. And ED course is usually like three to four sentences. Typically, what I do is I just put in a sentence, um, on presentation, Mr X vitals with this, I'll list out the vitals. And then I'll, I'll say like, uh, basic labs and imaging will obtain which were notable for. So the things that were notable, again, I'm not putting all the labs, but if the BMP was 10,000 or whatever, like anything that was super notable, super pregnant, I just put them and I say, pray them by comments. And then I say he was giving this, this, this, and those. So let's say it was giving like IV phyrosomite, 80 milligrams, this, this, this and that. I put what they did. I'm not putting any diagnosis. I just put what they did. And then I put he was subsequently admitted to internal medicine for further management. That's it, right? It's usually like three sentences. And then after that, I then go from the ED course to review of systems because my review of systems is essentially one sentence in my HPI like, Oh, Mr. This endorses blah, blah, blah, blah, blah. Those are the present, but pregnant positives, but demise, black, comma, black, comma, black, comma, black, comma, period, right?

Once I do that, so my review of systems, I always put that as a header, but I say 10 point review of systems was conducted and is otherwise negative, except as noted in the HPI. Boom, that's it. And then after that, I put the pass medical history, it kind of filled that out, pass medical history, fill that out. The meds, I try to put the meds, the dose, the meds and the dose and the dose in regimen, right? And then after that, I put the allergies, I put the family history, I put the social history, right? Smoking, drugs, if it's like I'm on an OB-GYN rotation, I'll put like sexually active with who and all that stuff, or if it's pregnant, right? And then after that, I do the physical exam. Again, this one I do have a template for. So I have a template for like a priority in the number of physical exam. So I just copy it, paste it into my notes, and then I modify, I edit it, right? So don't put a normal physical exam, and please don't put physical exams, you actually do not end up doing enough, right? I edit that, right? And then after that, I have a section that I call labs and image, and again, I don't put all of the patients, uh, vitals or whatever. The only things I put down are things that are pertinent, the things that are positive. If the sodium is normal, I don't include it. Anything that is normal is not included in my labs and image and section.

I just put that and you see some people, they copy the radiologist's impression and dump it into the anode, I don't do that. I'll just say, a CT with IV contrast was notable for this. So my notes are very like not cluttered in general, right? And then after that, I go to my assessment and plan, right? And my assessment and plan, I always put a shock like three sentence like paragraph, um, um, and I call it like a power statement, right? So for example, let's say a person is, let's say I do, I will do something like this, like Mr. X is a 55 year old male with a mathematical history of hypertension and anti-tune diabetes, who presented with a chief complaint of shortness or breath. On admission, his vitals were notable for profound hypertension, with a physical exam revealing by basal acroacols on the scotation of the lungs. Notable labs were notable for a BMP of 10,000 mild hypochalemia and ametabolic acidosis. Given the, and then I'll say, a chest x-ray obtained was positive for, um, sexualization of his pulmonary vessels, which was consistent with pulmonary dima. Given the presentation, physical exam and lab and imaging findings, the most likely etiology of Mr. X's presentation is a CHF exacerbation. That's my power statement. And then, boom, I go to problem number one. And again, I've told you how I make up my problems. Shift complaint, abnormal labs, anything that was brought up on imaging diagnosis and the acronyc medical problems. Those are the four things.

And then the thing is, as I write these problems, I try to, um, basically like my plan for each problem, I try to answer three questions. Again, if you notice I'm very algorithmic in the way I work, when you have like an algorithm in your mind for doing something, you're actually super efficient in that thing. I wish I had to answer three questions. First question, what is the objective data that I used to make this diagnosis? So for example, like if I put like CHF exacerbation as a problem, I'll put like BMP was, you know, noted to be 10,000 chest x-ray consistent with sexualization of pulmonary vessels and pulmonary dima. So that's how I assess the problem that, okay, this is a CHF exacerbation. And then the next thing I do is, what am I doing about it? And that's literally my next sentence. And I don't put like this variable statements. No, no, no, I just put IV-phyrosamide 80 milligrams TID or something like that. That's an astronomical dose of a phyrosamide by the way, although, you know, I've done a few people before that, you know, really needed it. But, you know, 80 milligrams phyrosamide IV-TID, right? And then the next thing I'm going to do is, and then I'm going to write, how am I going to track this problem so that I know what I'm going to be doing next. And I'll talk about this follow-up, you know, like prayer around, you know, patients in a different podcast. So like, how am I going to track this? Like, I'm going to check, like, oh, what's the Iurina output?

Like, what's their, what's their, what's their volume status? Like, like, do they have like three plus a dima to deal with something? I'll just keep track of those things, right? So basically, like, I usually have written like maybe like 95% of my note before I even see the patient. And this whole process of like writing a note, blah, blah, blah, blah, you know, probably take like 30, 40 minutes. Which again, that takes time, right? When I go to see the patient, it can be a lot more focused, right? I'm not going to like reinvent the wheel, that someone has already invented, right? So after I do that stuff, I go see the patient, and then I clarify those things, I do my own full physical exam based on what I think is wrong with the patient. And you know, I see them, get them admitted, talk them in, discuss the plan with my senior, make any changes to my note, and then I sign my note. And then the thing is the same moments. The next thing I literally do is I start writing my discharge summary, right? Because the most annoying section of the discharge summary is the hospital course. Most of the other sections tend to be very templated. So I write the, I start writing my discharge summary. And the thing is every day, I just been like 30 seconds to a minute modifying the discharge summary based on any new events that have come up in the patient's hospital course.

And then it's no big surprise that when a patient is ready to be discharged, I really have like a complete hospital course that's very detailed. I just copy it, paste it into the hospital course section, fill out the other sections real quick. And then most of my discharge summary is probably to be like five minutes or less to write in in my entire year. So that's how you go about admitting a new patient. It's not a painful process, pretty straightforward. Again, just have an approaching your mind. So I'm just giving you an idea of my approach. I'm not saying my approach is perfect, but that's what, as always, work for me. So as I do at the end of every podcast, I do offer one or one tutoring for many exams. Step one, step two, CK, step two, CSTEP three, pre-clean school med school exams, 30-ish-off exams. I do longitudinal tutoring where if you're like, if you're studying off any year in med school, I'll tutor you for like all your exams during that year. And at the same time, I'm also tutoring you for your upcoming USML exam. And then over these booster courses, it's 20 hours for step one for step two, CK and for step three. Very high-yield in an integrated format, we review the most notes for each of the different disciplines that are represented on your test. Again, I've done this with tons of people. Many people have gotten very good score increases. And then also do coaching for two things. So one is for like era's applications.

If you're a medicine applying to residency or AMCA's applications, if you're a college student applying to a med school, again, I help people out with personal statements, adding applications, mock interviews, rec letters, things like that. Again, I've worked with tons of people with tricky applications like low scores, no research, graduated from med school 10 years ago, failed a USML exam, no honors, nothing. Like all those things I've helped people navigate those tricky situations and many of them have matched. So again, interestingly, any of those things reach out to me and I'll be glad to point you out in the right direction. And then one of the things I offer coaching for, which I kind of remember, there are some things I literally do with people that I don't even advertise. But one thing I've done with many people in the past is like coaching on how to be good interns. So it's usually like a 20 hour course who work through like the highest your diagnoses that you'll likely see as an intern. I'll walk you through like how to write your notes, how to work up these problems and all those things. And again, it just helps people start off an intern year on a solid footing and they feel very confident in the abilities. Especially again, people that are studying on a like a word based, word based, uh, um, rotation or whatever. Right. So if that's something you're interested in, I feel free to reach out to me and I'll be up here to give you some more information.

And please subscribe to the You Tube channel. It's called Divine Intervention, USML podcast and videos. I also have a app like the podcast and Apple podcasts on Spotify and Google Play. Please subscribe to those. And then, um, please subscribe to my Word Press website is Divine Intervention podcasts with an S at the end at gmail.com. And if you have any questions about tutoring and oh, I forgot. I also offer tutoring for like the medicine, internal medicine and the pediatrics, in training exams and board exams. So if you have any resident friends that need those, feel free to reach out to me. And then also tutor for the MCAT and most pre-made science subjects. So if you need information on any of those things, reach out to me through the website or send me an email at Divine Intervention podcasts with an S at the end at gmail.com. And I'll be happy to point you in the right direction. So thank you for listening. There's more life less than to do because I got around for a meeting in about three minutes. So I'll talk to you later. God bless you. See you next time. Thank you.

Less than one hour, if practicing efficient techniques.

The Emergency Department (ED) note and the Triage note.

Bolding those specific items in the draft note to ensure they are addressed with the patient.

1) Chief complaint/presentation, 2) Super abnormal labs, 3) Any imaging findings/diagnoses, and 4) Chronic PMH.

1) What objective data supports this diagnosis? 2) What intervention is being performed? 3) How will this problem be tracked or followed up on?

By using one sentence format and listing only positive findings (e.g., "Mr. X endorses dyspnea, cough, and fatigue").

To write as much of your note as possible beforehand, making the in-person visit more focused and high-yield.

The medication name, the dose, and the regimen (e.g., "Lisinopril 10mg daily").

A "Power Statement" that synthesizes demographics, PMH, chief complaint, notable PE/labs/imaging, and working diagnosis.

Only include pertinent positives; omit anything normal or routine to prevent clutter.

Use one sentence format and list only positive findings, followed by "and otherwise negative."

Because those problems still need to be actively managed during the hospital stay.

To write as much of your note as possible beforehand, making the in-person visit more focused and high-yield.

The medication name, the dose, and the regimen (e.g., "Lisinopril 10mg daily").

A "Power Statement" that synthesizes demographics, PMH, chief complaint, notable PE/labs/imaging, and working diagnosis.

Only include pertinent positives; omit anything normal or routine to prevent clutter.

Use one sentence format and list only positive findings, followed by "and otherwise negative."

Because those problems still need to be actively managed during the hospital stay.