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--- medical_student:denver_health [2023/08/22 22:27] – [Rounds] haley.d
+++ medical_student:denver_health [2025/05/06 15:00] (current) – haley.d
@@ Line 4: / Line 4: @@
 [[resident:corrine_wong|Dr. Corrine Wong]]\\
 [[resident:stephanie_malliaris|Dr. Stephanie Malliaris]]\\
+[[resident: haley_desjardins | Dr. Haley Desjardins ]]\\
 ==== Contact Information ====
 PRS NP: Rosa DiPrima. 256-558-3028\\
-PRS Clinic RN: Aimee Harmon. 719-661-1555\\
+PRS Clinic RN: Aimee Harmon. 719-661-1555 (MESSAGE FOR FU)\\
 Attendings:\\
 Stephanie Malliaris: 617 970 7590\\
 Corrine Wong: 972 322 2078\\
+Haley Desjardins: 207 838 1957\\
+Surgery Schedulers:\\
+Ortho: Jacob Geesling\\
+Plastics: Christine Archuleta
+==== Haiku Setup ====
+{{ :medical_student:dh_haiku.pdf |}}\\
+{{:medical_student:initial_patient_activity.png?400|}}
+\\
 ==== Replant/Fellow Hand call ====
 There is a google calendar that is shared that has the schedule of fellow call. It is shared amongst the two ortho hand fellows and the senior plastic surgery resident. Add yourself to 4 weekdays and 1 full weekend for the month you are on. Can be any dates of your choosing (ie multiple weekdays in a week) but first come first serve as far as dates. You will only be called for operative interventions. For the weekdays, this mostly means replants as other cases get pushed to the next day. For the weekends, means replants, nerve repairs,pus/washouts. All attendings take 1 week at a time starting at 5pm Friday\\
 \\
@@ Line 39: / Line 52: @@
 Every day at 6am, you must log into the plastic surgery service team and plastic surgery consult team on Epic. If patient's get admitted during the day, you must unassign yourself, and re-assign yourself to the team for nurses to know who to contact. All consults come through Epic. If nurses message you with concerns, please try to address or discuss with a senior prior to adding senior resident or attending to Epic chat.\\
-The weekend is split between Urology and Plastics, so as the intern you will cover both of these services. Please let the weekend intern know who is on call and give them the appropriate phone numbers. Additionally, the plastics intern now covers the RGB patients after they have rounded. \\
 You are encouraged to update this wiki as needed. Please update your name and phone number above. Especially at the end of the rotation as you are signing out to the next intern, please take a few minutes and update the wiki and make sure the next intern has access. You will be asked for feedback on the wiki one week before the end of the rotation -- this will improve your fellow intern's experience.\\
 Intern tips\\
-- Almost daily needed wound dressings: xeroform, bacitracin/vaseline, kerlex, ABD pads, ACE wraps, scissors, tape. Get more than you need. You can also ask the day before what kind of dressings to have ready on rounds\\
--If there are rotating sub-I students, you can have them collect necessary supplies and prep consents for the day. Often the attendings will have the exact procedure and associated risks noted in their attestations on the clinic note. You also should feel free to confirm the consent with the senior.
 - Take MACRO pictures. Include the whole leg and the foot. Square your pictures with the chest and include both shoulders, breasts, etc... If you are taking pictures in the operating room, make sure to ask what structures are exposed (ie tendons, vessels, bone).\\
 - For I&Ds: 500ml bottles of NS, I&D kit, TUMI syringe, suction, ABD pad, sterile gloves, 1% lidocaine w/ or w/o epi, acute pain meds for patient (50mcg fentanyl)\\
@@ Line 79: / Line 88: @@
 ==== Rounds ====
 - The residents on service at DG will round on the plastic surgery service. The senior resident will communicate with the primary attending regarding patient care. \\
+- Almost daily needed wound dressings: xeroform, bacitracin/vaseline, kerlex, ABD pads, ACE wraps, scissors, tape. Get more than you need. You can also ask the day before what kind of dressings to have ready on rounds\\
+-If there are rotating sub-I students, you can have them collect necessary supplies and prep consents for the day. Often the attendings will have the exact procedure and associated risks noted in their attestations on the clinic note. You also should feel free to confirm the consent with the senior.\\
 - Please ensure that the first case of the day has a new or interval H&P pended in the chart in order to expedite preop process.\\
-On the weekend, if there is a primary plastics patient, this person will be rounded on by the intern covering plastics, who will then communicate with the rounding resident. The rounding resident will signout patients to on call PRS resident.\\
+-The weekend is split between Urology and Plastics, so as the intern you will cover both of these services. Additionally, the plastics intern now covers the RGB patients after they have rounded. Please let the weekend intern know who is rounding and pass along the rounding resident's number. Please also signout any patients on the list to the XCV intern\\
+-The rounding resident will signout patients to on call PRS resident.\\
 ==== Cases / Clinic ====
@@ Line 97: / Line 111: @@
 When on plastics, check the board for attending cases.  For Hand cases with Malliaris, please communicate with the Hand Fellow and Ortho hand resident to make sure that Malliaris is covered appropriately.  \\
-Discharge instructions can be found in Kendra Keene's smart phrase list. They all start ".DCXYC". Please place the appropriate discharge instruction and PACU discharge order set for outpatient cases.
+Discharge instructions can be found in most senior resident's smart phrase list, or under Kendra Keene where they all start ".DCXYC". Please place the appropriate discharge instruction and PACU discharge order set for outpatient cases.
 To make follow-up appointments: send a staff message in Epic to the scheduler and ask for a follow-up appointment in the time frame you'd like and include what surgery the patient had. Send to the following:
 -Hand patients: "DH PAV B ORTHO FRONT DESK" under pool (click the "to" button and then you will have the option to search a pool)
--Plastics patients: Julie, RN
+-Plastics patients: Aimee Harmon, RN
 Note for consents.\\
@@ Line 112: / Line 126: @@
 ==== CONSULTS ====
-- The plastics intern takes first call during the day for any plastics consults and occasional face call, but will notify the fellow ASAP.
+- The plastics intern takes first call during the day for any plastics consults. We do not see hand or face consults. \\
-- When called for a consult (ER or inpatient), the intern is responsible for 1) seeing the consult as soon as possible, and 2) presenting the patient to the fellow/attending on-call who may ultimately assume care of that patient.  \\
+- When called for a consult (ER or inpatient), the intern is responsible for 1) seeing the consult as soon as possible, and 2) presenting the patient to the midlevel resident on-call who may ultimately assume care of that patient. The resident will generally staff directly with the attending  \\
+- Dr. Wong covers all PRS consults unless Dr. Malliaris is on call for hand that week. When Dr. Malliaris is on hand call, she also covers PRS call.\\
- Please keep in close contact with attendings and Kendra, as cases will get added on.\\
 === Pressure Ulcers ===
-Pressure ulcers come in waves at DH. PMR wants to see patient before surgery at a pre-operative appointment. Physical therapy, occupational therapy and PMR should be consulted on day 1 regardless of activity restrictions.
-For any wound consult, make sure you know nutritional status, if the wound is infected, reason for admission, overall prognosis of the patient, and an assessment of resources for wound care after surgery.
+MOST PRESSURE SORES ARE NON-OPERATIVE.\\
+Pressure ulcers come in waves at DH. PMR wants to see patient before surgery at a pre-operative appointment. Physical therapy, occupational therapy and PMR should be consulted on day 1 regardless of activity restrictions.\\
+For any wound consult, make sure you know nutritional status, if the wound is infected, reason for admission, overall prognosis of the patient, and an assessment of resources for wound care after surgery. Below can be copied into the PRS consult note for all pressure sores and contains all required criteria to be optimized prior to surgical intervention. \\
+Surgical closure of pressure sores has a high rate of failure. To maximizing the patient's chance for success, the following criteria must be met prior to consideration of soft tissue closure or reconstruction for chronic pressure ulcers: \\
+- Wound:\\
+The patient must have source control. Staged reconstruction can be considered for a clean wound after adequate debridement and antibiotic therapy optimization.\\
+Debridements should be performed by the patient's primary surgical service or by the general surgery service. \\
+If evaluation for osteomyelitis or bone biopsy is desired, the orthopedic service should be consulted. Often an MRI is necessary.\\
+The infectious disease service should be involved for antibiotic recommendations. \\
+The clean wound should be managed with a wound vac whenever possible until ready for soft tissue closure. There should be evidence of the ability to form healthy granulation tissue in the wound. If wound care recommendations are needed in the interim, please consult the wound care team.\\
+- Nutrition:\\
+Albumin > 3.0 gm/dl\\
+Prealbumin >16 mg/dl. \\
+In general, patients with osteomyelitis and inflammatory processes do not have a normal prealbumin (negative acute phase reactant). However, if they can show consistent elevation in prealbumin over 3 weeks, they can be considered candidates for reconstruction. A nutrition consult should be ordered if these goals are not being met.\\
+- Medical comorbidities: \\
+Medical comorbidities, such as diabetes, must be well controlled.\\
+Control of any spasms or release of fixed contractures that may impair flap mobilization should be obtained prior to soft tissue closure.\\
+A bowel regimen must be well established and urinary control must be obtained. If necessary, stool diversion must be arranged prior to soft tissue closure. \\
+- Postoperative disposition: \\
+Pressure relieving surfaces should be used during hospitalization and should be obtained for outpatient use prior to closure (e.g. mattress, wheelchair). \\
+Outpatient wound care, if needed, should be arranged.\\
+Medical management follow up and rehabilitation plan should be set up. \\
+Physical therapy, occupation therapy, and social work should be involved with the disposition process.\\
+Once these parameters have been met, the patient can follow up with Dr. *** in outpatient plastic surgery clinic for evaluation. \\
 ==== Replant Protocol ====
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   *If following pathway, typically discharge POD 4 or 5
+\\
+\\
+==== Discharge Summary ====
+Discharge summaries need to include a complete list of every diagnosis or medical issue that impacted your patient’s care during their hospitalization in the discharge summary. The discharge summary is the first documentation that coders review. If the diagnosis is not present in the DC summary, even though it was treated during the hospital course, payers use this discrepancy to deny payment.
+Ways to phrase things: Apparently there is  widespread use of the words “in the setting of” to possibly link conditions together.  For coders to link conditions together, the physicians and APPs need to use linking verbiage like “due to”, “secondary to”, or “with”.  Do not use “iso” or “in the setting of”.