Admission Orders (ADC VANDALISM)

• Admit to: Floor, service, MD
  
• Diagnoses (prioritized)
  
• Condition: Good, fair, poor, guarded, critical
  
• Vitals and monitoring: Frequency of monitoring (eg,, q4, q shift, per routine), type of monitoring (eg, continuous oximetry, telemetry, arterial line, CVP, end-tidal CO2)
  
• Activity: Ad lib, bed rest with or without bathroom privileges, crib with side rails up, restrictions, ambulate TID, and so on
  
• Nursing/respiratory: strict I/O, daily weights, turn patient q shift, dressing care and changes, drain care, NG care, Foley care, suctioning, pulmonary toilet
  
• Diet: Regular, clear liquid, special requirements (ie, ADA, low fat, low calorie), restrictions (ie, 2-g sodium renal diet), NPO
  
• Allergies: Medication and food
  
• Labs
  
• IVF: Type, volume, rate (specify mL/hr for all; for infants, also specify mL/kg/d)
  
• Studies
  
• Medications: Name, dose (also specify mg/kg), frequency, route, duration, reason

Preoperative Orders

• Diagnoses (prioritized)
  
• Procedure
  
• Preoperative labs (including blood bank orders)
  
• Preoperative studies
  
• Diet: NPO/IVF after midnight, and so on
  
• Consent form signed and on chart
  
• H&P reviewed

Discharge Orders

• Discharge: When, to where
  
• Diagnoses (prioritized)
  
• Diet
  
• Condition
  
• Activity: Ad lib, bedrest, physical limitations, and so on
  
• Special needs: Home health needs, monitoring, and so on
  
• Discharge medications
  
• Discharge instructions: When and why to return, where to return, and so on
  
• Follow-up appointments

On-Service Note

• Admit date
  
• Admit diagnoses (prioritized)
  
• Hospital course summary
  
• Physical examination
  
• Problem list (prioritized)
  
• Assessment or plan (problem based or system based)

Progress Note (SOAP Note)

Subjective: Patient comments or complaints, nursing comments, relevant events

Objective:

• Vitals: Temperature, HR, RR, blood pressure, oxygen saturation, weight (including change from previous)
  
• I/O: Totals and components of IVF, PO intake, emesis, residuals, urine, stool, drains
  
• Physical examination (focused)
  
• Medicines: All current medicines with weight-based dose (scheduled and prn)
  
• Laboratory and test data: New or pending

Assessment: Analysis of above, including differential dx or tentative dx

Plan (problem based or system based)

Discharge Summary (Usually Dictated)

• Admission and discharge date
  
• Admission and discharge diagnoses (prioritized)
  
• Service: Service name, attending physician, resident(s)
  
• Consulting services
  
• Procedures
  
• Physical examination and vitals (admission)
  
• Hospital course (system based or problem based, pertinent labs and studies)
  
• Physical examination and vitals (discharge)
  
• Discharge condition: Improved, good
  
• Disposition: To outside hospital, home, hospice, and so on
  
• Discharge medications: Name, formulation, dosage, length of treatment, refills
  
• Discharge activity
  
• Discharge diet
  
• Discharge instructions: Dressing or cast care, symptoms to warrant further treatment, where to return for further treatment, and so on
  
• Follow-up appointments

Feedback and Evaluation Tips

• When done well, feedback and evaluation are powerful teaching tools, convey concern to learners, and are an essential component of clinical education.
  
• Feedback and evaluation should be a two-way dialogue. It is imperative that learners monitor their own performances.
  
• Take notes on your learner and base comments on observable behavior.
  
• Avoid vague statements such as, “Good job.” Be specific and concrete.
  
• Establish a nonthreatening climate and use a private location.

The Feedback Session

• Ask learners what they thought of their own performance.
  
• Encourage them to be their own critics.
  
• Establish dialogue.
  
• Deal with behaviors the learner can directly modify and control.

SET-GO framework for feedback sessions:

• What I Saw. (Describe what you saw as observer.)
  
• What Else did you see? (What happened next?)
  
• What do you Think about scenario? (Reflect back to the learner.)
  
• What Goals are we trying to achieve? (Dialogue with learner)
  
• Offer suggestions to facilitate learner achieve the goals.

The Evaluation Session

• Offer an objective grade based on objective observations and events (use notes).
  
• Grade the learner using known objectives established at the beginning of the learning experience.
  
• You are expected to evaluate your learners. This is a judgment of performance.

G-R-A-D-E framework for evaluation (Fam Med 2001; 33(3):159):

• Get ready.
  
• Review expectations and evaluation process with the learner very early.
  
• Assess (observe, record notes, have the learner self-assess throughout experience).
  
• Discuss (formal assessment meeting at midpoint of experience).
  
• End with a grade (offer suggestions and praise, discuss future learning points).

SPIKES Protocol: A Six-Step Process for Delivering Bad News (Oncologist 2000;5:302)

Weight

• Average birth weight: 3.2 kg (girls); 3.6 kg (boys)
  
• Regain birthweight by 7 to 14 days (7–10 days for term infants; 10–14 days for preterm infants)
  
• Doubles in 4 mo, triples in 12 mo, quadruples in 24 mo

Weight (Rate of Gain)

• 0–3 mo → 20–30 g/d
  
• 3 mo–6 mo → 20 g/d
  
• 6 mo–1 yr → 10 g/d or 1 lb/mo
  
• 2 yr–puberty → 0.5 lb/mo or 2 kg/yr

(*Abnormal prepubertal velocity = <1 kg/yr wt gain)

Height

• Average birth length, 50 cm
  
• Doubles in 3 to 4 years; triples by 13 years
  
• Infant growth rate, 0.8 to 1.1 cm/wk
  
• Often grow in 8-wk spurts separated by periods of slow growth or stasis (∼18 d)
  
• Reach half of adult height by 2 to 2.5 years (see Endocrinology chapter for more detail)
  
• First 6 mo: Growth rate influenced by intrauterine environment
  
• Male growth spurt during Tanner 4–5; female during Tanner 3–4

Height (Rate of Gain)

• Rule of thumb: 10-4-3-3-2 (inches gained per year until 5 years)
  
• Gain average of 10 inches in first year of life, 4 inches in second year, 3 inches in third year, 3 inches in fourth year, and 2 inches in fifth and each subsequent year until puberty
  
• Abnormal prepubertal height velocity <2 in/yr ht gain

Head Circumference (FOC)

• Average birth FOC: Girls, 35 cm; boys, 36 cm
  
• Usually 1 to 2 cm greater than chest circumference at birth
  
• Most head growth complete by 4 years
  
• Brain weight doubles by 4 to 6 months and triples by 1 year (similar to overall weight)

FOC (Rate of Gain)

• 0–3 mo → 2 cm/mo
  
• 3–6 mo → 1 cm/mo
  
• 6–12 mo → 0.5 cm/mo
  
• 12–24 mo → 2 cm total

Fontanelle

• The posterior fontanelle closes by age 4 mo.
  
• The anterior fontanelle is smaller by age 6 mo and is closed by age 9 to 18 mo (workup if open at 18 mo).

Sutures

• Usually all closed by age 12 to 24 mo, ossified by 8 years, and, completely fused by early adulthood

• Catch-up: FOC by 18 mo, weight by 24 mo, height by 40 mo (correct for gestational age until these age limits when plotting)
  
• Exception: VLBW (very low-birth weight) infants: Girls catch up by 20 years, but boys remain shorter and lighter than control subjects

°F = (°C × 9/5) + 32

°C = (°F 32) × 5/9

Kg = lb/2.2

Pounds = kg × 2.2

Grams = lb × 454

Quick Approximation #1 (Using Weight Only)

Quick Approximation #2 (Using Weight Only)

(most accurate >10 kg)

Mosteller’s Formula

(N Engl J Med. 1987;317(17):1098)