In patient Unit Admissions and On-Call Assessments 
 Consult Service
Expectations for Feedback to Students

1. History and Physicals-
• Histories should have a complete HPI with the Chief Compliant, an adequate description of pertinent signs and symptoms that stem from the Chief Complaint or other positive findings in the general psychiatric screening, a risk assessment, and Pertinent Negatives.
• Histories should be well organized, easy to follow, and in general follow a clear time course.  Write concisely.
• Components of assessment include substance history, past psychiatric history, family psychiatric history, Past Medical History (include neuro history), medications, allergies, and social history.
• Labs that are pertinent or pending
• Physical exam with proper emphasis on Neurological exam
• Mental Status Exam
• Assessment (the 5 Axis)
• Plan  

H & P’s are done on all admissions.  

2. Progress Notes: SOAP notes
• S-Subjective Pertinent things the patient tells you during the course of your interview with the patient.
• O-Objective
  Includes Vitals, pertinent physical exam findings, Mental Status Exam, labs, other test results
• A-Assessment
  5 Axis and/or a problem list that is being addressed during the admission
• P-Plan
  What is being done or is yet to be done to address the diagnosis/problem that is listed directly above (You may have multiple Assessment and Plan sections)  

Progress notes need to be done daily on each patient unless instructed otherwise by your service. The 1^st progress note after the admission should be especially rich with information as all the initial labs are completed in the work-up to rule out medical sources of psychiatric illness.  

3. Pre-rounds
   • Prior to attending led work rounds.  Medical student should review their patient’s charts for any events that happened overnight or over the weekend.  Check for results of any pending lab tests, consults, radiology studies, etc.  Read chart of any new admissions (if a team with another student(s), divide the new admits among yourselves)
   • Begin to meet with your patients.  Depending on time constraints before work rounds, your interviews with known patients may be brief check ins.  (Have longer interview later)  For new patients begin the H & P.  If pressed for time, get the HPI now, the rest later.  
     
     
4. Interviews - 
   
   
5. Presentations of patients to service -  
   
   
6. Mental Status Exam
   • Be able to describe all the aspects of a mental status exam.  Appearance & Behavior, Speech, Mood & Affect, Thought Process, Thought Content (including perception) Cognition, Judgment & Insight
   • Be able to properly perform a Mini-Mental Status Exam on patients  
     
     
7. Participation in work rounds
   • Know your patients.  Be able to do brief or full presentation as needed.  An important aspect of this is obtaining and reviewing old records.  (This can require some extra work.)
   • Be able to show you pre-rounded and are on top of your patient’s situations
   • Demonstrate your growing knowledge of psychiatry as you ask pertinent questions and answer attending’s questions during rounds.  Important areas to focus on are:
     1. describing various areas of the Mental Status Exam
     2. the signs and symptoms to look for in making a diagnosis (i.e. read around your patients)
     3. coming up with a reasonable and complete differential diagnosis
     4. being able to reason why one diagnosis of the differential is more or less likely than another based on what is known
     5. Awareness of the treatment plan objectives for each patient
     6. Able to work with other members of the team to get all the work done.  This includes covering for other team members when necessary and providing other team members pertinent information about your patient when you need coverage.
8. Discharge Planning
   • Assemble team work rounds directives, treatment team meetings, social work input, etc. ·        
   • Work with social work, patient’s family, and the patient to set up as ideal a situation for the patient as possible for follow up out-patient treatment so as to adequately address the biological, psychological, and social aspects of the patient’s illness.
   • Participate in family meetings for purposes of psycho education of both family and the patient.  Patient psycho education is not limited to family meetings.

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New patients

• Similar to H&P’s on in-patient unit or on call.  Typically cases will be assigned by the senior resident first thing in the morning or as the consults come in.  

Ongoing patients

• Daily notes unless told otherwise by service attending until the team signs off on case.
• Pre-rounds may be more difficult. To do a thorough job you may need to touch base with someone on the patient’s primary service and be up to date.  The need to do this will vary with the specifics of the situation. 

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Students should expect regular feedback from their attendings and residents on the work the students do.  This includes feedback on:

• written H&P’s,
• written SOAP notes,
• supervised interviews,
• presentations and specific aspects of presentations (risk assessment, mental status exam etc.)
• general participation in work rounds

Feedback, ideally, should be often, but brief-perhaps 1-2 minutes a day or every other day. Feedback should include identifying what the student has done correctly or especially well as well as constructive criticism and instruction on things the student needs to work on to improve.

Attendings are requested to give their students some mid rotation feedback at the three-week mark of the clerkship.  Ideally, if feedback is happening on an ongoing basis, mid rotation feedback may be brief.  At three weeks a review of the patient log (yellow card) with the attending is essential.

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