BUMC Basics.pdf - Anesthesia Home

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• Enter 2 initial zeros and then 9 digit BHVH account
number (begins with V)
• Press 2, begin dictating after the tone
DISCHARE SUMMARY OUTLINE
Attending:
Date of Admission:
Date of Discharge: Tell what facility they were
transferred to if applicable.
Admission Diagnoses:
Discharge Diagnoses:
Procedures/Tests:
Consultants:
Discharge Medications:
Follow-up:
Brief History & Physical:
Summarize the HPI and admission physical exam; it’s helpful
to the next provider if you also briefly review the MHx,
SurgHx, FamHx, Social Hx
Hospital Course: Most people organize this as a numbered
problem list. Mention the suspected etiology (CHF from
medication noncompliance, hypokalemia secondary to
diuretics, etc.) and explain what work-up, testing and
treatment was performed for each issue. Mention any studies
that are pending at the time of discharge. For simple admits
or for death notes, you can summarize the hospital course in
paragraph format.
MEDICAL RECORDS
Located in the basement of Jonsson. Access WebESA to
edit/review your dictations & electronically sign your charts
either in Medical Records or via the EMR (link on the left).
You have to keep up-to-date with your dictations/charts or you
lose your $50 monthly meal money and get yourself (and
possibly your attending) put on the “B list.” It’s painful …
made better by the giant cookies and snacks waiting for you
in Medical Records.
ADMISSION ORDERS
1. Admit to floor/ICU/telemetry
2. Attending: Dr.
3. R1—Dr. xxx—call 1st
R2/3—Dr. xxx
4. Service: Medicine teaching/CCU teaching