Communicate |
Communication Type |
“Call that process ‘curbside consult’. Page someone [ID] and get a drug recommendation, not a consult; just, ‘I was thinking this and wanted backup to say yes this is appropriate or not’.” |
Data Accessibility |
“Especially with ID because every six months they change their drug of choice/ protocol.” |
Collection Challenges |
“And how do you get all that information? You don’t do it in 5 minutes. You may not do it in 5 hours. But, you feed data in anyway you can.” |
Gather |
Information Type |
“The name, the objective things that you know about it, the subjective things that you know about it, and then the appraisal from those things and then a plan.” |
Information Source |
“WebCIS resources: drug, Infectious Diseases sources.” |
Document |
Documentation Method |
“Usually when writing my note I think of more things. Then you are at a computer anyway, so you order more lab tests for the following morning.” |
Documentation Medium |
“But as long as he can learn to use the machine, which your generation all can and a lot of my generation doesn’t use the machine very well. And so it’s really like pulling nails to get them to put their records in and their orders in on the computer.” |
Plan |
Define Plan Goals |
“Two levels at night when admitting and planning: 1) what does patient need acutely to be stabilized (antibiotics, urgent neuro consult); and 2) what to do in order to get patient ‘tucked’- tucked in and not going to die on you…” |
Medication Plan |
“So kind of like taking into account all of their problems. For each problem, thinking is there a certain medication they should have? If they come in with a fever, what antibiotic should they have?” |
Therapeutic Plan Scope |
“… an internist is really on the other side of the coin [and] really has to look at it as a function of everything that the patient has lived through, gone through, and their genetic predispositions...” |
Information Needs |
“Routine medications I know most of the side effects, but a lot of medications that you only prescribe once in awhile, especially antibiotics you may not know. So I always check myself. It takes like two seconds.” |
Errors |
“People make documentation errors; not always accurate- left side is right side and [you] have to check. Electronic documentation doesn’t make [it] easier.” |