The ASU (Ambulatory Service Unit) is our hospital based medical clinic. It serves a heterogeneous patient population from the surrounding area. This site affords the resident an opportunity to act as a primary care provider under the careful supervision of attending preceptors. The following is an orientation to the normal operations of the ASU.

Medication Documentation in Sunrise

Ground floor of the Widener Building immediately to the left as one enters the building.

Patients entering the ASU will first encounter the registration desk where registration and checkout occurs. After registration has occurred patients are taken to the clinical area for vital signs and chief complaint taken by the nursing staff. Patients are then placed in the exam rooms.

You will have 40 minutes for new patients (or patients not seen in the past three years) and 20 minutes for follow up patients. It is critical that you stay on time to ensure minimal patient waiting.

A universal encounter sheet (blue) has been developed and should be used for both billing purposes as well as ordering of referrals and other testing.

All vital signs are taken by the nursing prior to the patient entering the exam room. You are encouraged to repeat the blood pressure in both arms if the initial reading is elevated. A third reading at the end of the exam is often helpful. Thigh, large and pediatric cuffs are available.

After you see a patient the case must be presented to the clinic attending. If a physical finding needs reviewing, have the patient remain undressed on the exam table appropriately covered. You are expected to have an initial assessment and plan for each problem prior to presentation to the attending. After discussion with the attending this plan may or may not be be altered. As time allows attendings will be expected to teach management strategies of common outpatient problems.

You are responsible for performing the following exam components and procedures in the clinic setting:

Breast examinations

Rectal examinations

Pelvic exams with wet mount and cultures

PAP smears

There are 2 TDS computer terminals in the nurses’ station of the ASU. You are expected to be TDS trained upon arrival at your first clinic session.

The chart is organized into multiple sections. Labs and tests are on the left. Separate sections for the general medicine clinics and the subspecialty clinics are on the right. GYN/Ob notes are not included but may be obtained by calling the GYN clinic.

Initial visits to the ASU must be documented on the preprinted H+P form. All subsequent visits are documented by SOAP notes and must be co-signed by the attending. At every encounter you must rewrite the patients medications on the progress note you are using.

On the front of the chart you will find 2 blue sheets. It is mandatory that these sheets are filled out for each patients. This will help you reorient yourself to the patient at each revisit. It will also help other clinicians not familiar with the patient in handling intercurrent problems. These sheets must be filled out in their entirety and kept current.

If the patient has diabetes then it is only necessary to list diabetes in the Problems section. All other diabetes related issues including meds, labs etc. must be filled out on the yellow diabetes flow sheet.

If the patient has HIV then it is only necessary to list HIV in the Problems section. All other HIV related issues should be entered on the pink sheet.

On the back of the blue sheets are the guidelines for recommended health maintenance. We (and insurance companies) will be using adherence to these guidelines as a measure of the quality of care that you give.

Referrals to subspecialists must be indicated on the blue universal encounter form. For patients reffered to subspecialty clinics in the ASU In each exam room are appropriately sheets of paper for each subspecialist. You are to indicate the question for the subspecialist on this sheet and place it in the appropriate part of the chart. If the patient is referred outside of the clinic setting for consultation complete a blue consult form (hospital form) and give the patient the original to take to the consultant. A copy can remain in the chart.

For patients having labs drawn at AMH the encounter form should be filled out indicating the labs to be drawn. Forms for ordering labs for managed care patients are located in each exam room.

For labs that are performed at the AMH lab the following nomenclature is in use:

Basic metabolic panel Na/K/BUN/Cr/Cl/CO2

Comprehensive metabolic panel Na/K/BUN/Cr/Cl/AST/ALK PHOS/T.BILI/Chol/

CBC WBC/Hg/Hct

All labs will be returned to your mailbox in the ASU. It is important to keep the log in the Conference Room current regarding any tests that you order . It is also important to check your mailbox on a daily basis to look for returned labs and not wait until your clinic day. With daily surveillance important abnormalities will be taken care of expeditiously.

Most of the patients seen in the ASU are either self pay or Medical Assistance HMO. Because of this the referral options to specialists are limited. Most patients are required to attend the subspecialty clinics also located in the ASU. Rotating physicians and residents staff these clinics. It is important to be cognizant of the schedules of these clinics. Some of these clinics meet monthly or bimonthly. For patients who require urgent consultation, special arrangements may need to be made. Some consultants will see patients in their private offices.

The ASU has a small lab at the end of the dental hallway. In the lab you will find a microscope with slides and cover slips, a centrifuge and dip sticks for urine glucose and ketones.

In the nurses station is a closet for supplies. In this closet is a locked closet for medication samples. It is required that all samples that are given to patients be signed out in the sample log book (name of drug, quantity and lot number) and approved by the attending physician.

We offer several vaccines in the ASU. The nursing staff administers vaccinations should your patient require a vaccine. The following vaccines are provided at the ASU:

Influenza

Pneumoccocal

MMR

Hepatitis A

Hepatitis B

Tetanus

If you receive a phone call from a clinic patient it is required that you record that contact in the chart. This is to help ensure the delivery of quality care as well as to protect you from medical legal issues arising in the future. If you are on campus and can get to the chart it is recommended that you record the call directly in the chart. If you are off campus or can not get to the chart it is required that you fill out a sheet in the black notebook ‘On-Call Record’ The pages in this book are self stick with water. When you are able to come to the ASU it is required that the filled out pages are given to Lana or Eileen (nursing staff) for placement in the chart.

Patients who are admitted form the ASU are followed on the Chiefs service. This is an R3 run service with backup by attending physicians. You are highly encouraged to see your patients on the day of the admission and write a short note. This helps the treating team as well as being good for patient care. If you are admitting your patient directly from clinic, photocopy your encounter note (including problem list and medications) and send this with the patient to the ER or directly to the floor.

Your patients are covered at night by the R3 on call in the hospital. If you are in clinic in the late afternoon and send your patient for blood work or other testing that needs to be followed up that evening you must personally follow up the tests or sign it out to the covering R3. It is the responsibility of the R3 to inform you the following day of any important calls that occurred overnight as well as to use the on-call book for recording purposes.

In the ASU conference room are several reference texts including Harrison’s Principles of Internal Medicine, Branch’s Office Practice of Medicine, Barker’s Ambulatory Medicine, PDRs as well as other reference texts. There is access to Medline via the conference room computer.