Intern’s Guide to Success on Shift at GW ED

Written by Melanie Schroeder, Class of 2026
Last Updated 7/9/24

First steps when you arrive:  #

1. Find your senior (they are usually sitting at one of the 3 seats at the end of the dogbone by room 13-14) 
2. Figure out who (if anyone) you’re taking signout from 
   • Morning D shift (9a-5p) and Weekend E shifts (2-10p) you won’t be taking signout from anyone 
3. Set your stuff down at your seat at the dog bone (or back in the resident room – code 4911 DO NOT LEAVE THE CODE ON THE LOCK BOX AS 4911) 
4. Grab paper and pen and all your equipment to take signout and start your shift

Signout #

1. Person taking sign out sits while person giving sign out stands nearby
2. As an intern, a senior (or attending if senior is unavailable) should always supervise and help clarify plans 
3. The nitty gritty need to know: 
   • For undispositioned patients: EVERYTHING 
     • Age, relevant PMH 
     • presenting symptoms 
     • Notable exam findings (especially in neuro patients) 
     • Results that have come back 
     • Tests we are still waiting to come back 
     • To dos (person signing out should never leave you procedures or sensitive exams such as a rectal exam or vaginal exam) 
     • Disposition?? Discharge vs admit vs consults 
     • Give if then scenarios 
   • For patients with discharge orders placed (both houses) or patients with admission orders 
     • At minimum, a one liner about why they’re here and where they’re going (home vs SNF etc) or who’s admitting (team) 
     • If critically ill, more info is helpful and any to dos or if then planning 

After signout #

1. Click provider check in > assign yourself to the appropriate team > add your RF phone number next to your display name (and choose your color – highly encourage matching to your scrub color that day )
   
2. Find your RF phone and make sure it has battery 
   • Extra batteries are at the nursing station near green zone (hall H and I beds)
3. Sign up on the board (under P1) for any undispositioned patients i.e. people that don’t have 2 houses up or that don’t have admission orders placed by an admitting team a. Right click in the P1 box when you have the patient highlighted and select “Assign provider” 
   
4. Log into your team role on Tigertext
   
5. For any patients you sign up for: 
   • Briefly review their results and see if any new tests have come back
     • Can review on the Main Tracking List by hovering over lab/radiology columns and double clicking or in a patient’s chart by clicking “Results Review” on the left side of the screen
       
   • Go meet them all, give them an update, and re evaluate their status
   • Write assumption of care/accept signout notes on each one 
     • Double click on the prior resident/APP’s note to open it, add your timestamp/name under ED course 
     • Should include brief summary of pt’s presentation, what’s been done, what’s pending and suspected disposition
   • If you are waiting to hear back from a consultant or admitting team and it’s been a while (>1 hour): 
     • Send them a message saying you’re the new resident taking over and wanted to check in if they have seen the patient/have any questions/need anything to admit, etc 
6. If you have new patients to see, especially if abnormal vital signs or concerning findings from triage > seeing those patients should take precedence over notes 

Priorities on shift #

1.  In general, this should be your order of operations: 
   • Attend to any critically ill patients 
   • Discharge or admit patients when their workup is complete (and they’re doing well on re-evaluations / vitals are normal or well explained) or you have enough to argue for admission 
   • Send consults 
   • See new patients (note: this takes priority over all else if patient has signs of critical illness) 
   • Write notes 
2. Every time you sit down at your computer, you should individually run your own list in your head to see how you can move through the above priorities 
   • When stuck or just periodically: run your lists with your senior/attending

Placing Orders #

• When you see a patient, they may already have orders from triage or from when the senior or attending saw the patient before you
  • That’s normal and okay!!
  • When you see the patient, talk about the plan with the attending ( +/- senior if you have lots of questions) to determine if you need to put in any other orders
• You can place orders from the tracking list or from within a patient’s chart
  
• All orders are STAT! (Medications, labs, imaging, everything)
  
• If there are any big changes in the plan or tests/meds that need to be done urgently > find the nurse and communicate with them and coordinate to make these things happen
  • You can find the nurse assigned to a patient on Cerner, or if you’re ever unsure, it’s ok to ask the charge nurse
• Any other updates in the plan, should be communicated on the Tracking board under “Comment 2”
  
  • Examples:
    • “labs, imaging, meds > dispo”
    • “ CT result > 4 surg”
    • “4MAR” – MAR is medical admitting resident, i.e. the hospitalist team
    • “US result, OB recs, PO challenge”
  • “Comment 1” is generally used to indicate whether or not a patient has orders as well as any imaging updates
    • Examples:
      • A pt has imaging tests ordered:
        • 4XR, 4CT, 4MRI
      • A pt is currently in imaging (nursing/techs usually update this):
        • iXR, iCT, iMRI
      • A pt has admission orders:
        • +ICU ORDERS
        • +ORDERS
        • ○ +CCU ORDERS
• Once you have evidence that a patient will need to be admitted (and confirmed w attending) > place the decision for admission/observation order on Cerner
  

Writing Notes #

• The logistics
  • Go under documentation on the left side bar
    
  • Click add
    
  • Go to pre completed (next to Encounter pathway/Existing) and use Dr Potenza’s General Medical Problem template
  • Under title change it to ED Visit – “fill in the blank with whatever patients chief complaint is”
    
  • Press ok
• What should be included in EVERY note
  • Date/time seen (this is a hard stop in the note and it won’t let you sign unless you complete this)
    
  • The HPI
  • A clinically relevant physical exam including vital signs
    
  • Under the Assessment/Plan section
    • Write your MDM blurb under here
      • This is a paragraph that includes a one liner including relevant PMH and chief complaint(s), relevant vitals/exam, your differential diagnosis (should include rationale supporting what you think is going on as well as rationale refuting what emergent conditions you don’t think the patient has), and your plan (what labs/imaging/interventions you are ordering), as well your suspected disposition plan
        
  • Under ED Course
    • Add a Timestamp with your name and then any updates throughout the shift
    • Examples:
      • Results that have come back and when you reviewed them/ your own individual interpretation of them
      • Any new tests/interventions you’ve ordered based on new information
      • Times you’ve talked to consultants and what their recommendations are
      • All re-evaluations of the patients symptoms and exam
      • When patients get admitted/their status at that time
  • Under medical decision making
    • Click “Review/insert order profile” to include all orders for the patient
    • Include EKG interpretation here
    • Click “lab results” and include all lab results that return
    • Under radiology results: include any reports that come back
      
      
  • Procedures
    • Use the templates under M for Macro to document any procedures you performed
      
  • Do not need to change/write anything under Review of Systems – per HPI is enough
  • Under Impression & Plan
    • Diagnosis
      • Should include: patients chief symptoms as well as any diagnoses we’ve confirmed on shift (both related to chief complaint and incidental)
        • Easiest to search under “IMO”
          
    • Condition (at time of discharge/admission)
    • If being discharged (not if admitted):
      • Launch Patient Education
      • Launch Follow up
    • Counseled
    • Disposition
      • Include order for “discharge request” or for “decision for admission/observation” by clicking “Review/Insert Order Profile” or you can order the discharge/admission straight from the “Launch Disposition Order” tab
        

Consults/Admits #

Two steps –

1. Place the order “Consult to Provider”
   a. Priority: EMERGENT (everything’s always emergent/stat in the ED)
   b. Choose *Specialty consulted
   c. Write a brief reason for consult in the tab (there’s a relatively short character limit)
   
2. Tigertext the person you are hoping to reach with the full story
   • At a minimum, you should include:
     • Name
     • MRN
     • Reason for consult / your question for them (arguably the most important)
     • Brief history
     • Any pertinent exam findings
     • Results back and any pending

Patients with Psychiatric Concerns #

• If FD12 (name for an involuntary hold in DC – of note, can be done by the police as well as by healthcare providers in the ED or from psychiatry) or suicidal ideation with a plan or suicide attempt or homicidal ideation or homicide attempt:
  • Will need “medical clearance” labs (this is institution specific and even if we think a patient has no medical concerns based on their history and exam, we are obligated to do so due to ~politics~)
    • CBC
    • BMP
    • UA w micro
    • UDS
    • Ethanol level
    • Salicylate level
    • Acetaminophen level
    • EKG
    • Covid swab
    • +/- TSH with reflex, RPR
    • Any other labs/imaging you deem clinically relevant based on their symptoms
      
    • Needs a 1:1 sitter order
    • For FD12 only: needs “ED Mental Health Hold Request”
      
    • Ensure that the attending, senior, charge RN know that the patient is under a mental health hold
  • If patients require hard or soft restraints: these need orders in Cerner and need to be evaluated frequently to determine continued need for them (should be documented in Cerner)
    

Discharging a Patient #

• 2 ways to write up the paperwork:
  • Within the note (preferred because it will autopopulate into your note)
    • Under Impression & Plan as above (note what items are required)
• From the lollipop symbol on Tracking list (**NOTE: if you write up a discharge this way, you still need to ensure it all ends up in the Impression & Plan section of your note)
  
• When you think a patient is ready for discharge: confirm with the attending who saw the patient
• You will put up a “red house” aka the residents house by putting an order in Cerner for “Discharge request pending physician approval”
  
• The attending will put up a “brown house” aka a million other names and alliterations based on the attending’s name
  • They should place this order unless they explicitly ask you to do so
    • If so, this is done by placing an order for “Discharge Request: home routine”
      
• In the Comment 2 column:
  • When you’re working on writing up the discharge paperwork: write “dci in prog”
  • When the paperwork is complete write “dci done rx **” where ** is the number of prescriptions you’ve written and the number of paper prescriptions nurses are expecting to bring over to the patient when they discharge them
    
    • All prescriptions that are printed out need to be physically signed as well