Vernon Jubilee Hospitalists

We are VJH Hospitalists

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Our Vision

A vibrant, fulfilled group of health care providers enriching everyone we serve through excellent care.

Our Mission

Embracing integrity, adaptability and compassion, we strive to provide excellence in medical care to our community while maintaining a collaborative team of balanced and fulfilled providers.

Our Values

Efficiency

We believe that high quality care is in the best interests of both patients and providers.

Optimizing our performance improves patient care as well as work-life balance for ourselves, creating adequate time for family and personal activities.

Adaptability

We recognize that we work in an ever changing environment and believe that innovation and flexibility are crucial to our growth and succcess.

Integrity

When we make decisions, we strive to do what is right over what it is easy.

We strive to live our values, rather than just professing them.

Humor

We recognize that our work can be stressful.

To manage this we use optimism, hope, humility and laughing to reinforce our resiliency together.

Harmony

To us, good leadership means fostering teamwork and collaboration.

We practice compassion and empathy with ourselves and those we come in contact with.

What good is an idea if it remains an idea?

Try.
Experiment.
Iterate.
Fail.
Try again.

Change the world.

Simon Sinek

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H&P

HOSPITALIST ADMISSION NOTE
Vernon Jubilee Hospital

ID: []

Referred by: []

REASON FOR ADMISSION:
[]

HISTORY OF PRESENTING ILLNESS:
[]

GOALS OF CARE:
MOST []

PAST MEDICAL HISTORY:
[]

PAST SURGICAL HISTORY:
[]

ALLERGIES:
[]

HOME MEDICATIONS:
[]

SOCIAL HISTORY:
[]

IMMUNIZATIONS:
[Up to date]

FAMILY HISTORY:
[None relevant]

EXAMINATION:
Vitals:  

General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I - XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]

SPECIAL INVESTIGATIONS:
Labs:

Imaging:

ASSESSMENT & PLAN:
[]

DISPOSITION:
Admit to VJH Hospitalist
VTE: [Early Mobilisation] [Enoxaparin] [Apixaban] [Heparin]
Diet: [DAT]
Consults: [PT, OT, TL, SW etc]
EDD: []
BARRIERS TO DISCHARGE: []

Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.

Anatomy of the progress note

SUMMARY

  • Age of patient
  • Presenting complaints/symptoms
  • Special investigation findings (positive and negative findings)
  • Adverse reactions
  • Complications in the ward

 

4 Sections are Helpful in the summary

  • MOST – allows evening doc to see MOST when he/she opens the chart when called
  • REASON FOR ADMISSION – provide context to why patient is admitted
  • SUMMARY – Running summary of events, resolved issues (if you are using AI, this section will be utilized to format the summary when added to the context)
  • PAST MEDICAL HISTORY – Import and update this list (helps the AI make conclusions to summary)

 

Pro-Tips:

  • Keep it shorthand (makes it easier to edit)
  • Keep it up to date
  • Think what does a colleague doing a consult need to know

 

TODAY

  • SOAP NOTE – simple and straightforward, but what are you doing today

 

PROBLEM LIST

  • list active and relevant problems that are keeping the patient in hospital
  • Keep it short hand, relevant and updated
  • The past medical history will capture diabetes, hypertension, COPD, cancer etc if this is not the reason why the patient remains in hospital

 

Pro-Tip: 

  • Import the medication list from Meditech (if you need to discharge the patient the next day, AI will compare the H&P med list with that of the progress note and update your discharge summary accordingly, automatic med recon)
  • Antimicrobials heading – keep a list of antibiotics started and stopped during the admission (stewardship)

 

OTHER

  • EDD – update accordingly
  • Barriers for discharge – keep them updated
  • MOST – capture discussions around goals of care here (SDM, Patient wishes)
  • VTE – Update regularly (if your med list is in the note, you can actually see if Enoxaparin, DOAC is actually prescribed)

 

Inhalers