From the Guidelines
A comprehensive pre-charting checklist for new PGY1 internal medicine residents should include gathering all relevant patient information, reviewing overnight events, organizing assessment by systems, and preparing a problem-based assessment with specific plans for each active issue, as supported by recent studies such as 1 and 1. To ensure thorough patient care documentation, the following key components should be included in the pre-charting checklist:
- Gather all relevant patient information including vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation), recent lab results (CBC, BMP, LFTs, cultures if applicable), imaging reports, medication list, allergies, and previous notes.
- Review overnight events and nursing notes to identify any acute changes, as recommended by studies on checklist implementation in intensive care units 1.
- Organize your assessment by systems (cardiovascular, respiratory, gastrointestinal, etc.) and prepare a problem-based assessment with specific plans for each active issue.
- Include medication reconciliation details, noting any new prescriptions, dosage changes, or discontinued medications, which is crucial for preventing medication errors and ensuring patient safety 1.
- Document your physical exam findings completely, focusing on pertinent positive and negative findings relevant to the patient's condition.
- Prepare your assessment and plan with clear diagnostic reasoning and specific next steps, including any pending studies, consultations needed, and discharge planning considerations. The use of checklists in medical practice has been shown to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence-based best practices and safe high-quality care 1. Additionally, checklists can aid in the transition of patients from one care setting to another, such as from the laboratory to the cardiac intensive care unit 1. By following a comprehensive pre-charting checklist, new PGY1 internal medicine residents can ensure comprehensive documentation, facilitate clinical decision-making, prevent omission of critical information, and promote continuity of care between providers.
From the Research
Pre-Charting Checklist for PGY1 Residents in Internal Medicine
To effectively pre-chart as a new Postgraduate Year 1 (PGY1) resident in internal medicine, consider the following checklist:
- Review patient demographics and medical history 2
- Familiarize yourself with the electronic medical record (EMR) system and navigate to the patient's chart
- Review laboratory and radiology results, as well as any pending tests or studies
- Check for any active medication orders and allergies
- Review the patient's problem list and current diagnoses
- Identify any ongoing medical issues or concerns that need to be addressed
Clinical Scenarios and Management
When pre-charting, consider common clinical scenarios and how to manage them, such as:
- Hypertension and diabetes management 3, 4
- Cardiovascular disease prevention and treatment
- Medication management and potential interactions
- Patient education and counseling on disease management and prevention
Time Management and Efficiency
As a PGY1 resident, it's essential to manage your time effectively and prioritize tasks, such as:
- Allocating time for patient care discussions and direct patient contact 2
- Minimizing computer time and optimizing EMR use
- Delegating tasks and working with the healthcare team to ensure efficient patient care
Additional Tips
- Stay organized and focused during pre-charting to ensure accurate and thorough documentation
- Use resident-led curricula and educational resources to improve knowledge and skills in internal medicine 5
- Seek guidance and support from senior residents and faculty members when needed