MANUAL OF GENERAL INFORMATION
TABLE OF CONTENTS
The Addiction Psychiatry Fellowship Program .............................................................................................. 1 1. Mission Statement ............................................................................................................................ 1 2. Curriculum ........................................................................................................................................ 1 3, Goals and Objectives of Training ................................................................................................ 1-17 4. Residency Requirements ............................................................................................................... 17
a. Completion of a Psychiatry Residency Program ..................................................................... 17 b. BCLS Certification ................................................................................................................... 17 c. Duty Hours ........................................................................................................................ 17-19 d. E-mail Policy ............................................................................................................................ 19 e. Examinations ........................................................................................................................... 19 f. Medicare Time Reporting ........................................................................................................ 19 g. Program and Supervisor Evaluations ...................................................................................... 20 h. Supervision ............................................................................................................................. 20
5. General Information ....................................................................................................................... 20
a. Clothing Allowance .................................................................................................................. 20 b. Credit Union ............................................................................................................................. 20 c. Computer Services .................................................................................................................. 20 d. Dress Code and Decorum .................................................................................................. 20-21 e. Health and Disability Insurance ............................................................................................... 21 f. Housestaff Policies and Procedures Manual ........................................................................... 21 g. Keys ............................................................................................................................. 21 h. Library Services ....................................................................................................................... 21 i. Mail Room ............................................................................................................................. 21 j. Moonlighting and Locum Tenens Privileges ....................................................................... 21-22 k. Pagers ............................................................................................................................. 22 l. Parking Permit ......................................................................................................................... 22 m. Paychecks ............................................................................................................................. 22 n. Personal/Sick/Unpaid Leave .............................................................................................. 22-23 o. Photocopying/FAX ................................................................................................................... 23 p. Professional Development Fund ............................................................................................. 23 q. Resident Lounge ...................................................................................................................... 23 r. Vacation Leave .................................................................................................................. 23-24
6. Resident Standing, Progress and Promotion ................................................................................. 24 7. Remediation, Probation, Corrective Action, .............................................................................. 24-25 and Due Process 8. Hospital Communication Systems ............................................................................................ 25-26 9. The Dictation System ................................................................................................................ 27-29
1
THE RESIDENCY PROGRAM 1. MISSION STATEMENT The Addiction Psychiatry Residency Program has been established to provide training for psychiatrists interested in the practice of addiction psychiatry, and to enhance resources for addiction treatment in the State of Kansas and metropolitan Kansas City. The residency program includes clinical and didactic experiences that meet the requirements for addiction psychiatry training developed by the Accreditation Council for Graduate Medical Education. 2. CURRICULUM
2 months
KCVAMC
Adult Residential/Partial Hospitalization Treatment
10%
Johnson County Mental Health
Adolescent Addiction Residential
Program/Adolescent Center for Treatment
50%
KU Medical Center Methadone Clinic Suboxone Clinic
40%
9 months
KCVAMC
Adult Residential/Partial Hospitalization Treatment
30% Dual Diagnosis Clinic
40% Consultation/Liaison
20%
KU Medical Center Methadone Clinic Suboxone Clinic
10%
1 month
KCVAMC
Dual Diagnosis Clinic 30%
KU Medical Center Chronic Pain Management
60%
KU Medical Center Methadone Clinic Suboxone Clinic
10%
3. GOALS AND OBJECTIVES The addiction fellowship program has its primary site at the Kansas City VA Hospital in Kansas City, Missouri. There are additional rotations at the University of Kansas Medical Center (KUMC) in the Opioid Replacement Treatment Program and the Chronic Pain Clinic program. The fellow will have training in adolescent psychiatry at the Adolescent Treatment Program, which is a component of the affiliated training site at Johnson County Mental Health Center. The curriculum is developed in accordance with the six competencies. The addiction resident will have completed psychiatric residency training and is expected to have met
2
the competencies defined for general psychiatry. The following curriculum elaborates expected competencies more specifically for addiction psychiatry. The curriculum and evaluation methods are expected to evolve as the program gains additional resources for training. PATIENT CARE ACTIVITY EVALUATION METHODS AR Attending Rounds AE Attending Evaluation DPC Direct Patient Care PDR Program Director Evaluation FS Faculty Supervision DIDACTIC RESOURCES CAP Clinical Addiction Practice seminar BF Biological Foundations of Addiction CP Reading Seminar in Clinical Practice PSY Psychopharmacology Seminar BEH Behavioral Theory and Practice RD Research Design General Addiction Psychiatry Patient Care Principle Educational Goals Learning
Activity Evaluation Methods
Components of addiction treatment FS, ACR, CAP, CP
AE, PDR
Setting, duration, intensity FS, ACR AE, PDR
Placement criteria FS, DPC AE, PDR
Harm reduction in treatment settings FS, ACR, CAP
AE, PDR
Brief interventions FS, FSP, CP
AE, PDR,RN
Assessment instruments FS, CP AE, PDR
Role and use of community & regulatory agencies in treatment efforts
FS, CAP, CP
AE, PDR, SW
Family problems, enabling, codependency, counseling
CAP, CP AE, PDR
Pathophysiology & management of alcohol intoxication, withdrawal
BF, PSY, CP, DPC
AE
Pathophysiology & management of opioid intoxication, withdrawal
BF, PSY, CP, DPC
AE
3
Pathophysiology & management of stimulant intoxication, withdrawal
BF, PSY, CP, DPC
AE
Motivational to change theory and motivational interviewing
DPC, FS, CAP
AE, PDR
Group therapies CAP, CP, DPC
AE, PDR
Individual therapies DPC, CAP, CP
AE, PDR
Contingency management CAP, CP, BEH
AE, PDR
Network therapy CAP, CP, BEH
AE
Aversion therapies CAP, CP, DPC, PSY
AE
Therapeutic communities CAP, CP AE
Twelve-Step Programs in practice CAP, DPC, CP
AE, PDR, SW, RN
Twelve-Step Programs theory and research CP, RS AE
Other community support recovery groups CP. BEH AE
Medical disorders and complications of alcohol dependence
DPC, CP, PSY
AE
Medical disorders and complications of opioid dependence
DPC, CP, PSY
AE
Medical disorders and complications of stimulant abuse
DPC, CP, PSY
AE
Body fluid sampling for drug/alcohol use DPC, CP AE
Diagnosis of comorbid psychiatric disorders DPC, AR, FS, ACR, CAP
AE, PDR
Psychopharmacology of comorbid psychiatric disorders
FS, DPC, CAP, CP, PSY, RS
AE, PDR, RN
Group therapies of comorbid disorders FS, DPC AE, PDR
Individual therapies with cormorbid disorders FS, DPC AE, PDR, RN
Pain management for addicted persons FS, DPC, PSY, BEH
AE
4
Substance abuse in the workplace FS, CP, BEH
AE
Substance abuse in criminal justice settings CP, CAP AE
Addicted professionals and physician health programs
CP AE
Pharmacokinetic and pharmacodynamic principles in addiction
PSY, BF AE
Pharmacology of alcohol and sedative-hypnotics
CP, PSY AE
Pharmacology of opiate addiction PSY, CP, DPC, FS
AE, PDR
Pharmacology of club drugs PSY, CP, DPC, FS
AE, PDR
Pharmacology of stimulants PSY, CP, DPC, FS
AE
Pharmacology of hallucinogens PSY, CP, DPC, FS
AE
Pharmacology of marijuana PSY, CP, DPC, FS
AE
Pharmacology of inhalants PSY, CP, DPC, FS
AE
Basic science foundations of addiction treatment
BF, BEH, RD
AE, PDR
Brain reward circuitry and behavioral manipulations in addiction
BF, BEH AE
Stress, comorbidity and gene-based advances in addiction neuroscience
BF, BDH AE
B. Medical Knowledge Principle Educational Goals Learning
Activities Evaluation Methods
Understand the diagnostic process and criteria for substance-abuse disorders
CP, FS, DPC, CAP
AE
Perform brief interventions and individual psychotherapies for substance abuse
CP, FS, DPC
AE, PDR
Diagnose psychiatric disorders in presence of substance abuse
DPC, FS, CP
AE
Understand use of psychotropic agents for substance-abusing patients
FS, CP, PSY
AE
Understand stages of change and motivational interviewing
CP, FS, DPC
AE, PDR
5
Adapt treatment practices to various stages of recovery
DPC, FS AE, PDR
Assess and treat or refer medical and neurological disorders frequently associated with drug & alcohol abuse
DPC, FS, CP
AE
C. Interpersonal and Communication Skills Principle Educational Goals Learning
Activities Evaluation Methods
Elicit comprehensive history, MSE and diagnostic information with
Communicate effectively with patients and families in conflict
FS, DPC AE, PDR
Acknowledge stigma and demonstrate respect for patients
DPC, FS AE, PDR, RN, SW
Collaborate with patients to develop an acceptable and realistic treatment plan
CAP, FS, DPC
AE, PDR, RA, SW
Develop an effective rapport with patients and family members
DPC, FS AE, PDR, RN, SW
Communicate effectively with physician colleagues and health care professionals to assure comprehensive care
FS, DPC AE, PDR, RN, SW
Recognize impact of cultural and ethnic differences in communication and expectations
FS, DPC, CAP, CP
AE, PDR, RN, SW
Communicate effectively with treatment team members
DPC, CAP, FS
AE, PDR, RN, SW
D. Professionalism Principle Educational Goals Learning
Activities Evaluation Methods
Understand and implement concept of boundaries with patients and staff
FS, DPC, CAP
AE, PDR
Appreciate the social context of addiction treatment
FS, DPC, CAP
AE, PDR
Maintain timely and effective medical records documentation
FS, DPC AE
Assure availability of continuous care as needed for accepted patients
FS, DPC, CAP
AE
E. Practice-Based Learning and Improvement Principle Educational Goals Learning
Activities Evaluation Methods
6
Identify gaps in personal knowledge and skill in patient management
FS, DPC, CP
AE, PDR
Develop methods for systematic critical review of professional literature
CP, PSY, RD
AE, PDR
Commitment to practice of evidence-based medicine
CP, RD AE, PDR
F. Systems-Based Practice Maintain awareness of cost-effective
diagnostic and treatment practices CP, RD, CAP
AE
Effectively use community and business services to support patient care
CP, CAP, FSP, SA, RT
AE, PDR, SW
Collaborative approach to law enforcement and criminal justice system
CAP, DPC AE, PDR, SW
Adolescent Center for Treatment This residential treatment program is a component of Johnson County Mental Health Center, and is located in Olathe, Kansas. The Center provides substance abuse treatment services for individuals age 12 through 18. Approximately three-fourths of the adolescents are involved in the juvenile justice system. Over half of this population also has comorbid psychiatric diagnoses, primarily affective and conduct disorders. Treatment modalities include individual, group and family counseling using various approaches such as motivation enhancement and cognitive-behavioral therapy. Treatment is provided by a multidisciplinary staff including addiction counselors, social workers, a psychologist, nurse, and a child and adolescent psychiatrist. This is a two-month, part-time (50%) rotation. The addiction resident is expected to attend and participate in program activities for the initial two weeks of the rotation. Subsequently the resident will become involved with initial evaluations and development of individualized treatment plans, conducting mental status examinations and developing differential diagnosis of potential psychiatric disorders. The resident will meet with family members of the adolescent patients and will be expected to attend selected family therapy and treatment activities. The resident will receive supervision from the program director for psychosocial treatments, and from the child psychiatrist in regard to comorbidity diagnosis and medication management. A. Patient Care Principle Educational Goals Learning
Activity Evaluation Methods
Understanding of risk factors for addiction including genetic, family, peer and social factors
CP, CAP, BEH, FS
AE, PDR
7
Understand concept of resilience, and protective factors for adolescents
CP, CAP, BEH, FS
AE, PDR
Familiarity with various screening instruments and techniques for adolescent substance abuse
CP, CAP, BEH, FS
AE, PDR
Knowledgeable of epidemiology of substance abuse in adolescents
CP, CAP, BEH, FS
AE, PDR
Understand the role of denial and role-playing in context of substance abuse
CP, CAP, BEH, FS
AE, PDR
Know relevant state and federal law and regulations regarding right to privacy of the adolescent and involuntary treatment
CP, CAP, BEH, FS
AE, PDR
Know components of a complete mental status exam and developmental stages
CP, BEH, FS
AE, PDR
Knowledge of impact of biopsychosocial stage of development on substance abuse patterns
CP, CAP, BEH, FS
AE, PDR
Knowledge of treatment modalities including CBT, TC, 12-step, family therapy, relapse prevention, CRA
CP, BEH, CAP, FS
AE, PDR
Understand role of juvenile justice system in adolescent treatment
CP, CAP, FS
AE, PDR
Knowledge of placement criteria for adolescents
CP, CAP, FS
AE
Understand assessment dimensions for appropriate level of care
FS, CP, CAP
AE
Knowledge of epidemiology of comorbid substance abuse and psychiatric disorders in adolescent population
CP AE
Know risk factors for psychiatric disorders among adolescent population
CP AE
Understand diagnostic criteria for adolescent psychiatric disorders when associated with substance abuse
CP, CAP, FS, BEH
AE, PDR
Familiarity with potential psychopharmacological treatments for substance abuse in adolescents
PSY, CP, FS
AE
Understand psychopharmacology for comorbid psychiatric disorders
PSY, CP, FS
AE
8
B. Medical Knowledge Principle Educational Goals Learning
Activity Evaluation Methods
Conduct a comprehensive mental status exam for adolescents in treatment
FS, CAP AE
Use addiction screening instruments for adolescent populations
CP, CAP AE, PDR
Evaluate risk factors for addiction in adolescent populations
CP, CAP AE, PDR
Use motivational interviewing technique in treating adolescents
CAP, FS AE, PDR
Use specialized interviewing techniques to gather information with adolescents
CAP, CP, FS
AE, PDR
Use developmental stage to inform evaluation and treatment
CP, CAP, BEH, FS
AE, PDR
Gather and interpret information from multiple sources to reach diagnosis
CAP, FS AE, PDR
Use family therapy principles in treating adolescent patients
BEH, CP, FS
AE, PDR
Use cognitive-behavioral techniques and relapse prevention
BEH, CP, CAP, FS
AE, PDR
Adapt 12-step processes for adolescent use FS, CAP AE, PDR
Understand Community Reinforcement Approach
CP, FS AE
Apply placement criteria for level of care matching
CP, FS AE
Develop psychiatric diagnosis in presence of substance abuse in adolescents
CP, FS AE
Use psychopharmacologic agents for psychiatric disorders in presence of substance abuse
PSY, FS AE
C. Interpersonal Skills and Communication
Principle Educational Goals Learning
Activity Evaluation Methods
Ability to modify interviewing techniques to obtain history of substance abuse
CP, FS, DPC
AE, PDR
Establish understanding of confidentiality with family members and adolescent
CP, FS AE, PDR
9
Maintain non-judgmental attitude with adolescent
FS, BEH, DPC
AE, PDR
Modify interviewing strategy for patient developmental stage
CP, BEH, FS
AE, PDR
Ability to gather sensitive information such as history of abuse, trauma
FS, CP. DPC
AE
Use screening instruments to assess adolescents in general medical practice
CP, CAP AE
Assure communication among treatment team members and adolescent family
FS, DPC AE, PDR
Assure thorough understanding of use of psychopharmacologic medications
PSY, FS AE
D. Practice-Based Learning and Improvement
Principle Educational Goals Learning
Activity Evaluation Methods
Commitment to evidence-based practice CP, FS AE
Critical analysis of scientific studies of adolescent addiction treatment
RD, CP, FS AE
Use on-line resources to monitor emerging clinical literature
CP, FS AE, PDR
Develop patient database to monitor behavior changes over time
RD, FS AE
E. Professionalism
Principle Educational Goals Learning
Activity Evaluation Methods
Demonstrate reliable and ethical behavior DPC, FS, CP
AE, PDR
Assure continuity of care across medical specialties
DPC, RS AE
Demonstrate knowledge and compliance with laws and regulations regarding treatment of minor patients
CP, FS, DPC
AE, PDR
Understand impact of developmental stage on boundaries and roles
FS, DPC AE
10
F. Systems-Based Practice
Principle Educational Goals Learning Activity
Evaluation Methods
Knowledge of community agencies including law enforcement involved in adolescent behavior management
DPC, FS, CP
AE, PDR
Maintain awareness of trends in drug abuse among adolescents in community
DPC, FS AE, PDR
Monitor treatment availability within juvenile justice purview
DPC, FS AE, PDR
Monitor placement criteria and protocols in use by third-party payers in community and impact on treatment availability
DPC, CP, FS
AE
METHADONE AND SUBOXONE CLINIC FOR OPIATE ADDICTION, THE UNIVERSITY OF KANSAS MEDICAL CENTER The KUMC Methadone and Suboxone Treatment clinic is a required rotation, beginning with a two-month period of 50% time. During this period, the resident will become familiar with the treatment program, and will learn assessment and motivational strategies. This rotation provides experience in diagnosis and management of opiate dependence throughout the first year of recovery. The resident will work closely with the director and multidisciplinary team during the initial presentation and evaluation of the opioid-abusing person, and during initiation of medication assisted recovery. Emphasis will be on stabilization of addictive behaviors using substitution methods, and re-integration into the family and community milieu. The resident will have experience in diagnosis and management of patients with co-occurring psychiatric conditions, especially affective and anxiety disorders that are widely represented in this population. An important component of training is gaining understanding about the evolution of recovery stages throughout the first year of treatment. As the resident undertakes direct patient care, s/he will identify five patients to be followed in continuity clinic throughout the fellowship year. The resident is expected to understand all aspects of opiate replacement treatment, including clinical and administrative/legal requirements. In addition to methadone, treatment modalities include individual and group psychosocial and educational therapies, motivational enhancement, cognitive-behavioral, and 12-Step experience, and pharmacotherapy for addiction and comorbid psychiatric disorders. A fulltime psychiatrist with extensive experience treating substance dependence is Director of the Clinic, and will be readily available for supervision. The Clinic is staffed with a master's level counselor, addiction counselors, and nurses who are members of the multidisciplinary team to develop and implement treatment plans for patients entering treatment.
11
A. Patient Care Principle Educational Goals Learning
Activity Evaluation Methods
Neurobiology of acute opiate use and opiate dependence
BF, PSY, DPC
AE
History of opiate use and abuse; political and diplomatic issues
CP, CAP AE
Assessment and diagnosis of opiate dependence by DSM-IV criteria and ICD-9 criteria
CP, CAP, DPC, AR
AE
Psychosocial treatment methods for opiate dependence, including role of NA
CP, DPC, CAP, ACR
AE, PDR
Pharmacologic treatments for opioid dependence other than replacement
DPC, PSY AE, PDR
History and practice of methadone replacement treatment
DPC, PSY, CAP, FS
AE, PDR
Buprenorphine, development of office-based treatment and implementation
PSY, DPC, FS
AE
Diagnosis and treatment of psychiatric comorbid disorders
AE, PDR
Pharmacologic management of comorbid psychiatric disorders
PSY AE
Medical disorders and complications of opioid dependence
DPC, FS, CP
AE
Physical exam and characteristic findings for drug-abusing patients
CP, AR, DPC
AE
Management of prescription opioid abuse and dependence
DPC, FS, CAP
AE, PDR
Treating pain in addicted populations, relapse liability, diversion
CP, CAP, PSY, AR
AE
Law enforcement and forensic involvements common for drug-abusing patients
CAP, CP, BEH
AE
B. Medical Knowledge Principle Educational Goals Learning
Activities Evaluation Methods
Perform focused physical exam accounting for common disease stigmata
FS, DPC, CP
AE
Perform appropriate laboratory and imaging to fully evaluate medical status
FS, DPC AE
12
Perform thorough mental status exam and develop differential diagnoses
CP, FS, CAP
AE
Manage acute opiate withdrawal, prevention and treatment to resolution
CP, FS, PSY, DPC,
AE, PDR
Management of opioid overdose including multiple-drug complications
FS, DPC, PSY
AE
Knowledge of criteria for admission to methadone maintenance and understanding of Federal regulations for use of methadone
CP, FS AE, PDR
Perform methadone induction and subsequent dose regulation
FS, DPC, PSY
AE
Indications for use of psychopharmacologic medications in presence of opioid dependence
CP, PSY, FS, DPC
AE
Interactions and contraindications of pharmacological agents with methadone and buprenorphine
PSY, DPC, FS
AE
Manage post-acute withdrawal, craving and relapse
FS, DPC, CP, PSY
AE, PDR
C. Interpersonal Skills and Communication
Principle Educational Goals Learning Activities
Evaluation Methods
Develop understanding of idiosyncratic language frequently used by substance abusing patients
DPC, FS AE, PDR
Demonstrate respect in communication style and presentation with patients
DPC, FS AE, PDR
Provide education for patient and family members in culturally sensitive language
DPC, FS AE, PDR
Ability to communicate effectively with various law enforcement agencies and representatives
DPC, FS, CP
AE
Assist patients in communicating with social service agencies and State offices
FS, DPC AE
Maintain medical records and medication administration as required by Federal regulations
CP, FS, DPC
AE, PDR
Explain methadone treatment plan requirements and coordinate communications with treatment team
FS, DPC AE, PDR
13
D. Practice-based Learning and Improvement Principle Educational Goals Learning
Activities Evaluation Methods
Maintain knowledge of current treatment guidelines for addictions
CP, FS, PSY
AE
Ability to critically evaluate scientific literature in addiction treatment
CP, RD, BEH
AE, PDR
Demonstrate ability to use professional and non-professional information technology for patient care and education
CAP, FS AE
Learn systems of practice monitoring to identify errors and institute corrections
CAP, FS AE
E. Professionalism
Principle Educational Goals
Learning Activities
Evaluation Methods
Demonstrate responsibility for patients across various treatment settings
FS, DPC AE
Respond to communications from patients and other treatment providers in a timely manner
FS, DPC AE
Provide continuity of care including coverage when unavailable
FS, DPC AE
Maintain effective coordination of care with members of treatment team
FS, DPC, CP
AE, PDR
Participate in peer review activities for opiate replacement treatment providers
FS, CP AE
F. Systems-based Practice Principle Educational Goals Learning
Activities Evaluation Methods
Develop a systematic method to monitor changes in regulatory requirements
CP, FS AE, PDR
Develop collaboration with other agencies using opioid replacement treatment to monitor duplication of services or diversion activity
FS, DPC AE
Facilitate patients’ use of various community social services to improve patient care
DPC, FS AE, PDR
14
Understand the role of law enforcement in regulatory requirements and support of opioid replacement treatments
CP, CAP, FS
AE, PDR
CHRONIC PAIN CLINIC UNIVERSITY OF KANSAS MEDICAL CENTER
The Chronic Pain Clinic is located in the Psychiatry Department offices, directed by Teresa Long, M.D., who is board-certified if Psychiatry, Internal Medicine, and Pain Management. This clinic specifically cares for patients who have disorders involving chronic pain that are not associated with cancer (cancer pain is managed in another KUMC setting). Many of these patients require opioids for adequate pain control, and are expected to continue opioids for lengthy periods of time. The clinic has a multidisciplinary staff providing medical, psychosocial, and psychological treatments of pain. Because of the use of opioids, this clinic frequently must manage patients who are referred with characteristics suggestive of addiction and comorbid psychiatric disorders. Patients may be referred from KUMC acute medical/surgical inpatient services, outpatient clinics, and from practitioners in the metropolitan area. The chronic pain clinic has an active consultation service at KUMC, and typically sees an average if three consults daily.
This rotation provides experience in diagnosis and management of various pain disorders, including pseudoaddiction and opioid dependence. The resident works closely with the pain clinic director and the multidisciplinary team in both clinic and consultation roles. Emphasis is on differential diagnosis and management of individuals requiring longterm opioids, including the use of adejunctive medications, behavioral methods, contracts, body fluid monitoring, compliance, and pharmacologic management of comorbid disorders. Longterm use of opioids remains controversial, with quite limited sources of evidence-based practice; this rotation will prepare the addiction resident to assist general medical practitioners with issues of addiction in pain management. A. Patient Care Principle Educational Goals Learning
Activity Evaluation Methods
Neurophysiology of pain FS, CP AE
Interface of pain and addiction neurophysiology
CP, BF AE
Approaches to chronic pain management FS, CP AE
Psychological techniques for chronic pain management
FS, CP, CAP, BH
AE
Assessment of pain in presence of addiction FS, CAP AE
15
Non-opioid medications in management of pain disorders
PSY, CAP AE
Physical therapy and rehabilitative therapies CP, CAP, FS AE
Opioid medications for chronic pain management
PSY, CP, CAP, FS
AE
Controlled Substance Act and regulatory guidelines for opioid medications
PSY, CP, CAP AE
Buprenorphine and office-based treatment of addiction
PSY, CP, CAP AE
Addiction treatment programs, NA, and community support for pain patients
FS, CP, CAP AE
Relapse prevention in chronic pain disorders FS, CAP AE
B. Medical Knowledge Principle Educational Goals Learning
Activity Evaluation Methods
Understand diagnostic process and criteria for pain disorders
FS, CP, DPC AE
Perform appropriate physical examination, laboratory and testing to fully evaluate medical status
CP, CAP, FS, DPC
AE
Perform mental status exam and collect appropriate corollary information
FS, CP, CAP, DPC
AE
Develop differential diagnosis for chronic pain disorder and addiction disorder
FS, CP, CAP AE
Understand the use of the WHO ladder in pain disorders
CP, FS, DPC AE
Competent use of opioid medications including dose equivalents, tolerance, and withdrawal strategies
FS CP, CAP, DPC
AE
Develop addiction treatment program for patients taking opioids for analgesia
FS, DPC AE, PDR
Know regulatory and legal requirements for use of opioids
CP, PSY, CAP, DPC
AE
Provide consultation on addiction and pain management to other physicians
FS, DPC AE
16
Perform and supervise opioid withdrawal protocols
PSY, FS, DPC AE, PDR
Knowledgable RE regulations and implementation of office-based opioid treatment
CP, FS, PSY AE
Able to access current research findings for pain disorders and addiction management
PSY, FS AE
C. Interpersonal Skills and Communication Principle Educational Goals Learning
Activity Evaluation Methods
Communicate effectively to convey openness and respect for patient needs
DPC, FS, AR, CP
AE, PDR
Recognize impact of cultural and ethnic differences in communication styles
DPC, FS AE, PDR
Maintain communication with treatment team members to facilitate patient care
DPC, FS AE, PDR
Maintain accurate and timely records of prescribed medications
PSY, DPC, FS AE
Clearly document all aspects of medication compliance
DPC, FS AE
Organize information received from treatment team to develop treatment plan
DPC, FS AE
D. Practice-Based Learning and Improvement Principle Educational Goals Learning
Activity Evaluation Methods
Use on-line resources to monitor clinical literature in pain management
PSY, CP, CAP, FS
AE, PDR
Critical analysis of pain professional literature and practice guidelines
CP, RD, FS AE, PDR
Commitment to evidence-based practice CP, PSY, RD AE, PDR
E. Professionalism Principle Educational Goals Learning
Activity Evaluation Methods
17
Assure availability of continuous care and access to pain medications
FS, DPC AE, PDR
Demonstrate reliable and ethical behavior DPC, FS AE, PDR
Demonstrate compliance with state and federal regulations of opioid medications
DPC, PSY AE
Understand and implement concept of boundaries with patients
FS, DPC AE
F. Systems-Based Practice Principle Educational Goals Learning
Activity Evaluation Methods
Collaborate with pain management physicians to enhance treatment continuum
CP, FS AE
Maintain awareness of trends in drug diversion and abuse in own community
PSY, DPC, FS AE, PDR
Knowledge of community support groups appropriate for recovering people prescribed opioid medication for pain
DPC, FS AE, PDR
Facilitate use of office-based buprenorphine for patients with pain and addiction
DPC, FS AE, PDR
4. RESIDENCY REQUIREMENTS a. Completion of Psychiatry Residency Program. The Addiction Psychiatry
Fellowship program requires completion of an accredited four-year psychiatry residency program. A letter from the Residency Director at the training institution confirming completion of all requirements is necessary prior to acceptance in the Addiction Psychiatry residency.
b. BCLS/ACLS Certification. Residents are required to be certified in BCLS prior to the entry of the psychiatry residency program. Certification in BCLS is valid for two years. Please contact the training office at ext. 83214 for more information.
c. Duty Hours. Residency programs in the United States must comply with the
Accreditation Council for Graduate Medical Education's duty hours standards, which limit resident duty hours to a maximum of 80 hours a week and set other restrictions on duty hours. The standards, which the ACGME Board of Directors approved in February 2003, are the culmination of two years of work to develop common duty hours standards for residents in all specialties that balance the needs of patient care, resident well-being and academic and clinical education. Residency
18
Programs that fail to comply with the new standards will face adverse accreditation action, including loss of accreditation. While the Addiction Psychiatry program does not require on-call assignments, the program follows the guidelines of the ACGME standards, as follows: Resident Duty Hours and the Working Environment Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients.
Duty Hours
Residency programs in the United States must comply with the Accreditation Council for Graduate Medical Education's duty hours standards, which limit resident duty hours to a maximum of 80 hours a week and set other restrictions on duty hours. The standards, which the ACGME Board of Directors approved in February 2003, are the culmination of two years of work to develop common duty hours standards for residents in all specialties that balance the needs of patient care, resident well-being and academic and clinical education. Residency Programs that fail to comply with the new standards will face adverse accreditation action, including loss of accreditation. Following is an outline of the ACGME duty hours standards:
“Duty Hours (the terms in this section are defined in the ACGME Glossary and apply to all programs) Duty hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. 1. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. 2. Residents must be provided with one day in seven free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call. 3. Adequate time for rest and personal activities must be provided. This should 10-hour time period provided between all daily duty periods and after in-house call.
On-call Activities
19
1. In-house call must occur no more frequently than every third night, averaged over a four-week period. a) On psychiatry rotations, in-house call must occur no more frequently than every fourth night, averaged over a four week period. 2. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care. 3. No new patients may be accepted after 24 hours of continuous duty. a) a new patient is defined as any patient for whom the resident has not previously provided care.
4. At-home call (or pager call) a) The frequency of at-home call is not subject to the every-third-night, or 24+6 limitation. However at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. b) Residents taking at-home call must be provided with one day in seven completely free from all educational and clinical responsibilities, averaged over a four-week period. c) When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit”
d. E-mail Policy. Residents are expected to check their KUMC e-mail daily. It is
essential that residents stay in touch with the KUMC e-mail system, which is the most commonly used form of communication at KUMC.
The Kansas City VAMC e-mail policy is provided during orientation at that Hospital. The resident is able to access KUMC functions including library search engines and references, on-line journals, and KUMC e-mail.
e. Examinations. Mock oral board examinations are scheduled once a year for
residents in their last year of training and others preparing to take the oral portion (Part II) of the American Board of Psychiatry and Neurology specialty certification exam. The location rotates between UMKC, KUMC-Wichita and KUMC-Kansas City. All three of the residency programs participate. Additional Mock Board experience is a part of the scheduled educational activities during the Adult Outpatient Clinic rotation and is also available post-graduation on an individual basis with various faculty members.
f. Medicare Time Reporting. Residents are required to keep track of their hours
worked by entering the information into the E*Value online management system. Time entry for the previous week (Monday-Sunday) is required to be entered into the system by 9:00 a.m. every Monday morning. Residents who are consistently
20
late in entering their time will be reported to the Program Director. Instructions and training for time entry are available in the Residency Office.
g. Program and Supervisor Evaluations. Residents are required to complete online
evaluations of their faculty attending and the service to which they rotated at the end of a rotation or quarterly, whichever is earlier. Resident evaluations of attending faculty members and of rotations are completely anonymous and are not released until three online evaluations have been completed. Neither the faculty member nor the Residency Director (or anyone else) will be able to link specific faculty or rotation evaluations with specific residents.
h. Supervision. Clinical training includes regularly scheduled individual addiction
psychiatry supervision. Each resident receives two hours of individual supervision in addition to teaching conferences and rounds; one of these two hours is devoted to psychotherapy supervision.
5. GENERAL INFORMATION
a. Clothing Allowance. Three white coats are provided at the beginning of
residency.
b. Credit Union. Residents and their immediate families are eligible for membership in the Credit Union. They offer several savings programs, including a passbook account, Certificate of Deposit, and a money market fund, all at competitive rates. They make loans to qualified persons for any good reason. Other services include a notary service, traveler’s checks, and a VISA card. The Credit Union is located on the first floor of Delp Pavilion, Room 1037. (588-5375). Hours: Lobby - 8-4 M-F and Walk-up window - 7-8 am and 4-5 PM M-F.
c. Computer Services. Each resident is assigned a KUMC Network login and password for access to email, clinical data and the Internet. KUMC email can be accessed from outside KUMC via the Internet. Residents have access to computers throughout the department and in designated resident areas. Residents are expected to check their KUMC email once daily and required to check their KUMC email once weekly regardless of rotation. When assigned to the VAMC, residents will have access to KUMC functions and e-mail.
d. Dress Code and Decorum. White coats may be worn in all patient care areas and are required on certain rotations as determined by hospital policy and/or their staff supervisor. Scrubs are prohibited in all cafeterias. Residents are expected to present a clean, neat and professional appearance at all times. Beards and mustaches are allowed as long as they are properly maintained. Residents must
21
wear the Medical Center identification badge and nametag when involved in clinical or administration activities. Conduct consistent with the dignity and integrity of the medical profession is required in all contacts with patients, families, and other health professionals. Patient confidentiality is clearly a paramount issue, and discussions of any patient-related matters must not be conducted in public areas.
The use of alcoholic beverages or drugs that impair judgment while on duty is prohibited, as is the consumption anywhere on the VAMC or KU Medical Center premises. Refer to the Housestaff Policies and Procedures Manual for more detail.
e. Health and Disability Insurance. Health insurance is provided for all residents
and dependants for a minimal charge and is payroll deducted. Disability insurance is supplied for all residents by KUMC. The premium paid by KU provides coverage for $1,000 per month on a long-term basis, if a resident should become disabled. Additional coverage may be purchased by the individual. The disability insurance may be converted to a private plan following residency.
f. Housestaff Policies and Procedures Manual. This manual presents the institutional guidelines, policies, and procedures governing a wide range of resident issues at the University of Kansas School of Medicine and Medical Center. It can be accessed only through the Internet under the Office of Graduate Medical Education Home Page at http://gme.kumc.edu/documents/gmepolicyandproceduremanual.pdf.
g. Keys. The Residency Coordinator distributes the keys to the Olathe Resident Offices, Olathe Elevators, Common Areas and master keys to the Outpatient Clinic. Office and elevator keys must be returned to the Residency Office at the end of a KUMC rotation. Common Area keys should be returned at the end of residency training. At the Kansas City VAMC, keys will be distributed through the Mental Health Administrative Offices, and must be returned at the end of the training period.
h. Library Services. The Resident Library is located in the Residency Office. All
library materials must be signed out. The main library requires an ID number to check items out. Extensive on-line resources are available through Dykes Library, and may be accessed through the KUMC home page.
i. Mail Room. Every resident is assigned her/his own box in 1012-Olathe Pavilion. Department and hospital communications will be delivered there. It should be checked and emptied frequently. The addiction resident will have a mailbox assigned at the Kansas City VAMC.
j. Moonlighting and Locum Tenens Privileges. Residents are allowed to moonlight in accordance with the policies outlined in Section 16 of the GME
22
Housestaff Policies and Procedures Manual. Residents doing training on a J1 visa are not eligible to moonlight outside KUMC. Moonlighting residents are not allowed to work more than 96 hours per two months. A resident wishing to moonlight must have a permanent license in the applicable state. Individual malpractice coverage must be provided by the resident or his moonlighting employer at the maximum level of at least $1,000,000/3,000,000. Evidence of the coverage must be submitted along with the Department’s request forms. The extrainstitutional practice must be outside normal business hours of 8:00 a.m. to 5:00 p.m. and must not interfere with call duties or performance in the residency program. Any violation of these regulations will result in immediate termination of these privileges. Requests must be submitted well in advance and must be approved by the Residency Review Committee, the Department Chairman and the Executive Dean. The forms may be obtained from the Residency Office. Moonlighting residents must adhere to the policies set forth by the ACGME regarding duty hours as follows described in Section E, 8 above.
k. Pagers. All residents are assigned an alphanumeric pager to carry during residency. When assigned to a VAMC rotation, residents should carry both their VAMC and KUMC pagers. Residents are expected to return pages in a timely manner. Residents will be responsible for the replacement cost of a lost or stolen pager.
l. Parking Permit. The Department pays for one parking permit in the red zone for each resident. The Residency Coordinator has information regarding parking. Cars will be ticketed if parked in an improper location/zone. If for any reason a different car must be driven that does not have a displayed permit, Parking Services must be notified between 8:00 a.m. and 5:00 p.m. that day (they will need the license # of the car). If a ticket is received, it should be forwarded back to Parking Services with “courtesy” written on it. The fine will be waived.
m. Paychecks. The first paycheck will not be received until approximately one month after training has begun. Thereafter, residents are paid every two weeks, on Fridays.
n. Personal/Sick/Unpaid Leave. Residents may request up to three months per
year of leave for reasons of personal or family illness, serious health condition, disability, or the birth or adoption of a child. In most cases, residents elect to use allotted vacation and sick leave before taking unpaid leave. If time is taken as unpaid leave, stipend payments are suspended for that period, but all other benefits continue. Any unpaid leave that exceeds 4 weeks must be made up at the end of the residency program. For a brief illness or for other medical reasons, residents are allowed up to 10 days sick leave per year. These days do not carry over from one contract year to the
23
other and are clearly not to be abused. Please refer to the Housestaff Policies and Procedures Manual for further details. For women who are breast-feeding after returning to work, there is a private place designated to express milk in Room 2044 Wescoe Pavilion at KUMC. Residents who are aware of a medical leave in advance of the leave should complete a blue leave request form to ensure proper approval and coverage is obtained. RESIDENTS ARE REQUIRED TO NOTIFY THE RESIDENCY COORDINATOR AS WELL AS THE APPROPRIATE PERSONNEL AT THEIR ASSIGNED ROTATION BEFORE THEIR SHIFT BEGINS IF NOT REPORTING TO WORK DUE TO SICK OR MEDICAL LEAVE.
o. Photocopying/FAX. Residents have access to the department copier located 1012 Olathe. The code for the Residency Program is “1091”. The department FAX machine is also located in Room 1012 - Olathe Pavilion. The FAX number is 913-588-6414. (For professional use only).
p. Professional Development Fund. The Department provides $300.00 per year reimbursement for addiction psychiatry residents for such things as books, journal subscriptions, conferences and other educational expenses. Contact the Residency Coordinator to obtain a "Professional Development Reimbursement Request" form. Attach original documentation of expenses and turn in to the Residency Coordinator or the Department Administrator, Room 1005 – Olathe Pavilion.
q. Resident Lounge. The Shawn Storm M.D. Memorial Resident Lounge is located on the first floor of Sudler, just adjacent to the Child Psychiatry faculty offices. This is for use of the entire housestaff body. The door has restricted access through a keypad—the entry code is 157.
r. Vacation Leave. Residents are provided a maximum of 3 weeks (15 days) per year. The resident’s stipend is covered during this time. Vacation requests should be submitted in early July for the time period July-December and in early January for the time period January-June. Residents who request their vacation one year in advance will receive preference if a conflict arises with another resident’s vacation request. Vacation requests will not be approved for the last two weeks of June and the first two weeks of July. The Residency Review Committee will have the authority to approve vacation requests for these times only under extraordinary circumstances
All vacation requests must be initiated at KUMC. Always obtain a vacation request form from the Residency Coordinator so that she can verify the vacation balance.
24
Requests must be approved and signed by the attending staff, the Chief Resident and the resident(s) covering clinical responsibilities before submitting it to the Residency Office for final approval. Once approved, the Residency Coordinator will block the requesting resident’s clinic schedule for the requested time and notify the clinic staff of the resident’s leave dates and who is providing coverage for that resident in their absence. While on a V.A. service, residents need to submit additional vacation paperwork which may be obtained from the psychiatry secretary at the V.A. Requests will be considered on a first-come-first-served basis. Requests for vacation or professional leave submitted less than 30 days in advance will not be considered.
6. RESIDENT STANDING, PROGRESS, AND PROMOTION Residents are evaluated by their attending staff and nursing staff quarterly or at the end of each rotation (whichever is earlier). Evaluations are available for review on line when they are completed. Residents being evaluated will receive an email notification when an evaluation has been completed. These evaluations are to insure that residents are progressing satisfactorily from rotation to rotation and that deficiencies, if present, can be addressed as soon as possible. Residents are reviewed as to performance by the Addiction Psychiatry Residency Director and, as appropriate, at Residency Review Committee Meetings at regular intervals, at least twice yearly. 7. REMEDIATION, PROBATION, CORRECTIVE ACTION, AND DUE PROCESS Concerns regarding any aspects of a resident’s performance are brought before The Departmental RRC. One or two low satisfactory grades will result in informal counseling. A poor grade or unsatisfactory rotation evaluation will result in formal counseling, which may include development of a remediation plan, repetition of the rotation or probation. Consistently poor performance may suggest a need for adverse action. Very specific guidelines from the School of Medicine govern remediation, probation, and due process/grievance procedures pertaining to any such actions. Please refer to the appropriate section in the Housestaff Policy and Procedure Manual for details.
Whenever the Addiction Psychiatry Residency Director is informed of significant concern regarding a resident’s performance, the resident involved will be contacted and given the opportunity to provide a response. The resident may provide this response by any or all of the following: in the form of a written document, through verbal communication with the residency director, or by personal appearance before the departmental Residency Review Committee. The RRC will subsequently review the facts and make a decision as to whether this information should be included in the resident's permanent file. If a decision is made to place the material in the resident's file, both criticism and response will be included. Supervising faculty may include, in correspondence regarding concerns about
25
resident's performance, a proviso that same not be placed in the resident's file if difficulties are corrected within a given time frame.
8. HOSPITAL COMMUNICATION SYSTEMS The Paging System:
All the departments in the medical center use the Verizon pager system. The page numbers begin with 917 followed by four digits specific to the individual pager. You must dial 9 prior to dialing the pager number in order to gain access to an outside line. Leave your message, then press the # sign and hang up. Please refer to the Miscellaneous section of this manual for a list of the KU faculty and residents pager numbers. Each resident is assigned a personal pager that they will keep throughout their training. You may also call the page operator for specific pager information at extension 85155. The VA Hospital has a radio broadcast system. To page from inside the hospital, dial 86 and the page ID number. Enter the number where you want the call returned and hang up. Your pager is your responsibility. If you lose it or deface it you will be responsible for the cost of a new pager. Do not put tape on the pagers for any reason as it interferes with the inscribed numbers, voiding the warranty. Check your batteries frequently and replace them as necessary. Batteries are available in the mailroom at KU and from the department secretary at the VA. KANS-A-N Long Distance System This is a state long-distance network. It is for business calls only. The state of Kansas prohibits the use of long distance for personal use. To make a long distance call you must use only approved extensions. Dial 9, then 1, followed by the area code and the seven-digit number. To phone the KU-Wichita or KU-Lawrence campus, you simply need to dial the last four digits of the number (equivalent to the extension). Record all calls made on a Telephone Record form that is available from the mailroom, Room 1012 OP, and should be turned in to the department receptionist. KUMC Phone System: To make an outside call, dial 9 to get an outside line. To call another number in the hospital, dial the 5-digit extension number. All extensions within the hospital may be dialed directly from outside by adding the prefix 913-588-. Overhead Paging: The page operator (ext. 85155) can place a voice page for you on the overhead system. Overhead paging is not available in certain areas of Olathe Pavilion or in the library, so it will generally be more efficient to use the pager system.
26
The Paging System:
All the departments in the medical center use the Verizon pager system. The page numbers begin with 917 followed by four digits specific to the individual pager. You must dial 9 prior to dialing the pager number in order to gain access to an outside line. Leave your message, then press the # sign and hang up. Each resident is assigned a personal pager that they will keep throughout their training. You may also call the page operator for specific pager information at extension 85155. The VA Hospital has a radio broadcast system. To page from inside the hospital, dial 86 and the page ID number. Enter the number where you want the call returned and hang up. When you are outside the hospital, you may page someone by calling 816-922-3337 and following the directions given. Your pager is your responsibility. If you lose it or deface it you will be responsible for the cost of a new pager. Do not put tape on the pagers for any reason as it interferes with the inscribed numbers, voiding the warranty. Check your batteries frequently and replace them as necessary. Batteries are available in the mailroom at KU and from the department secretary at the VA. KANS-A-N Long Distance System This is a state long-distance network. It is for business calls only. The state of Kansas prohibits the use of long distance for personal use. To make a long distance call you must use only approved extensions. Dial 9, then 1, followed by the area code and the seven-digit number. To phone the KU-Wichita or KU-Lawrence campus, you simply need to dial the last four digits of the number (equivalent to the extension). Record all calls made on a Telephone Record form that is available from the mailroom, Room 1012 OP, and should be turned in to the department receptionist. KUMC Phone System: To make an outside call, dial 9 to get an outside line. To call another number in the hospital, dial the 5-digit extension number. All extensions within the hospital may be dialed directly from outside by adding the prefix 913-588-. Overhead Paging: The page operator (ext. 85155) can place a voice page for you on the overhead system. Overhead paging is not available in certain areas of Olathe Pavilion or in the library, so it will generally be more efficient to use the pager system.
27
9. THE DICTATION SYSTEM DICTATING AND REPORT REVIEW INSTRUCTIONS A central dictation system is available for all dictation of history/physical reports, consultation reports, operative reports, and discharge summaries. Dictation instructions are as follows: TO DICTATE A REPORT:
1. Dial 1-877-544-4999. There will be a prompt, “Welcome to the KU Hospital Central Dictation System”
2. To dictate a report, enter your 6 digit dictating ID number. 3. Enter the 2 digit report type: Discharge Summary 01 Speech/Language Evaluation 07 Transfer Summary (Stat Report) 03 Speech Therapy Progress Note 17 Operative Report 02 Video Swallow 27 Intraoperative Neurophysiologic Electroencephalogram 08 Monitoring Report 12 Evoked Response 18 Delivery Note/Operative Report 22 Endoscopy 09 History and Physical 04 Pediatric GI 19 Consultation 06 4. Enter the 7 digit medical record number. 5. Press 1 to dictate and 4 to pause. (Intermittent beep indicates pause mode – press 1 to
resume dictation.) 6. Press 5 or 9 to end current report. Job confirmation number will be announced. TO DICTATE ANOTHER REPORT WITHOUT CALLING BACK INTO THE SYSTEM:
1. At end of dictation, Press 5 on telephone keypad. The system will announce a job confirmation number for the report you just completed. 2. Enter the 2-digit report type.
3. Enter the 7-digit medical record number. 4. Press 1 to dictate and 4 to pause. (Intermittent beep indicates pause mode – press 1
to resume dictation.) 5. Upon pressing 5 or 9 to end current report, job confirmation number will be announced. NUMBER FUNCTIONS 1 - Dictate 5 - End current job/Start new #1 - Report review/Post-dictation listen 7 - Fast forward 2 - Dictate/Pause toggle 9 - Disconnect 3 - Short rewind 4 - Pause IMPORTANT REMINDERS
• Always call the Medical Record Dept. ext. 8-2432 (M-F, 7-4:30), ext. 8-2454 (after hours) when dictating a transfer (report type 03) to provide pertinent information regarding the patient transfer.
• Always press 9 to disconnect after completing your entire dictation or to disconnect if the ID digits have been entered incorrectly and the ready tone is heard.
• Always press 5 between reports if you are dictating multiple reports. Then repeat from step 3 of the dictating instructions listed above.
REPORT REVIEW Dial 1-877-544-4999. To review a report press #1. Enter your 6-digit user ID. To review by medical record number, press 1. After pressing 1, enter the 7-digit medical record number to hear the most recent dictation. To review a previous dictation on the same patient, press 5. To review another patient’s report, press 5, and enter the patient’s medical record number. To dictate press 1, or press 9 to disconnect. “Report not found” will be heard if a report is not available.
28
HISTORY & PHYSICAL REPORT REQUIREMENTS 1. Patient name - please spell out full name 2. Medical record number 3. Date of History & Physical 4. Expected Admission Date 5. Expected Surgery Date (if surgery is scheduled) 6. Chief complaint 7. Details of the present illness, including, when appropriate, assessment of the patient’s emotional, behavioral, and social status. 8. Relevant past, social, and family histories, appropriate to the age of the patient. 9. Significant past surgical history. 10. Any remarkable past medical history. 11. Inventory by body systems. 12. In services, as appropriate, for children and adolescents, the history must include: -- An evaluation of the patient’s growth and development -- The parent’s report or other documentation of the patient’s immunization status -- Consideration of emotional, cognitive, social and daily activities, as appropriate -- The family’s and/or guardian’s expectations for, and involvement in, the assessment, treatment and
continuous care of the patient. 13. Comprehensive current physical assessment. 14. A statement on the conclusions or impression drawn from the admission h&p examination. 15. A statement of the course of action planned for the patient while in the hospital. OPERATIVE REPORT REQUIREMENTS All operative reports must be dictated immediately following surgery. 1. Patient name - please spell out full name 2. Medical record number 3. Date of operation 4. Preoperative diagnosis 5. Postoperative diagnosis 6. Operation 7. Surgeon 8. Assistant surgeon 9. Description of the findings 10. Technical procedures used 11. Specimens including dispostion of the specimen 12. Referring Physician name, address, and fax number if available. CONSULTATION REPORT REQUIREMENTS 1. Patient name - please spell out full name 2. Medical record number 3. Admission Date 4. Consultation date 5. Consulting physician 6. Attending physician 7. History of present illness 8. Physical examination 9. Impression 10. Recommendation
29
DISCHARGE SUMMARY REQUIREMENTS All discharge summaries must be dictated within 48 hours following discharge. 1. Patient name - please spell out full name 2. Medical record number 3. Dates of admission and discharge 4. Attending staff physician 5. Dismissing hospital service 6. Reason for hospitalization 7. Significant findings including Physical Examination and test results 8. Treatment rendered/Description of hospital course 9. Final Diagnoses 10. Procedures performed 11. Instructions to the patient and/or family, as pertinent, to include:
a) Physical activity b) Diet c) Follow-up care d) Medications 12. Referring Physician name, address, and fax number if available. It is imperative that all diagnoses and procedures performed be dictated in the discharge summary, as well as being recorded on the discharge orders. For assistance with any dictation issues, please call Ext. 8-2432 or 8-2446 (M-F, 7- 4:30 p.m.) or Ext. 8-2454 any other time. For assistance with Radiology Reports call 8-1827.
SPEAK CLEARLY AND DISTINCTLY!