House Staff Manual - Winthrop University Hospital

2. Telephone orders are limited to emergencies only and are one time orders. If, of necessity, ordersare given over the telephone to a licensed practitioner who is required to write down the telephoneorder and read it back to you. The telephone communication must be signed at the earliest possiblemoment with a maximum time limit of 24 hours.3. Narcotic orders: a member of the House Staff may not write a narcotic order for a patient withoutpersonally evaluating and documenting this assessment in the medical record.4. Pathology orders: standing orders for Laboratory procedures must have a stop date included on thechart with the original order.5. Patient allergies and current medication must be listed on the first order sheet by the physician whohas completed the history and physical.6. Residents must immediately co-sign orders written by students.7. Orders are only to be written using WUH accepted medical abbreviations.DISCHARGE PROCEDURES1. The principal diagnosis (the diagnosis established after study to be chiefly responsible for admission)and secondary diagnoses are to be recorded on the summary sheet of the chart when the diagnoses areestablished, and must be on the chart at the time of discharge.2. In the event that the principal diagnosis has not been established at discharge, due to pending testresults, etc., write this information on the summary sheet at the time of discharge.3. The Discharge Order and Instruction Sheet is to be completed prior to discharge. Complete allsections in full, date, time and sign.4. The medical record must be completed by the House Staff as prescribed by Hospital policy to avoidthe accrual of delinquent charts.The Discharge Summary is the responsibility of the resident who has had on-going responsibility forthe patient. Should a resident be covering a patient for less than 48 hours at the time the patientexpires, is transferred or discharged, then the Discharge Summary is dictated by the previous resident.Dictation of the discharge summary is to be completed upon discharge or expiration. Disciplinaryaction will be taken if the discharge summary remains undictated following discharge.During dictation of the discharge summary, give the first and last name of the attending physicianresponsible for the case, to facilitate mailing procedures. Dictate according to discharge summary formatas follows below.DISCHARGE SUMMARY DICTATION PROCEDURESThe summary should be a concise overview of the case. When required, additional details will be found inthe chart.1. Discharge Summary Outline:Identify yourself as the person dictating.First and last name of attending physician must be included.Give patient's name and spell it.Give patient medical record number (6 digits)Give admission and discharge dates.Then continue with the following format:Speak slowly and clearly when dictating.Rev. 1/08