Things I wish every Nocturnist doctor or provider in hospital medicine knows!

I have been working a day time hospitalist for the last 10 years. Here I tried to put together some tips for the nocturnists to do the admission H&Ps in a way that helps the daytime Hospitalist rounders in the best possible way.

A good admission will help in giving excellent and timely care for the patient and this helps in better outcomes and reduce length of stay.

Here are some tips to consider for the nocturnists.

Always, come on time as there may be one or two admissions pending due to busy ER. ERs tend to give more admissions later in the day before their day shift ends.

Order all the important medications that the patient was on at home especially Anti-epileptics, long acting insulins, Beta blockers, Psych meds, Pulmonary meds like Advair or Symbicort, blood thinners etc. If you hold any medications due to patient being NPO or unconscious, please mention that in the Assessment and plan of your H&P.

Try to finish all the H & Ps before you leave home in the morning.

Before finishing a patient’s admission, go over all the labs and put corrective orders for abnormal electrolytes, antibiotics for leukocytosis if associated with infections, consults for severe anemia, or elevated LFTs, abnormal imaging studies, blood thinners if patient is on them, etc. Then think about the main diagnosis patient is being admitted and make sure you put order to take care of that issue.

Make sure to use Order sets where they are a must e.g. CHF, TIA/CVA, COPD, etc.

Do not forget to bill the patients.

Depending on how your patients are distributed in the morning, make sure all your patients are allotted to the day time hospitalists. Billing may help patient distribution especially the consults, ICU transfers if done in the night time etc. This is very important to keep your patient safe by leaving your patients in an other doctor’s hands to prevent issues later on.

Try to finish all the admissions that were signed out to you by ER.

If a family member of the patient tells any specific  precautions, requests, cautions or any other valuable info about the patient, please mention in H&P and put a note to the nurse about it. In EPIC, we can place a “Nursing Communication” e.g. Family requests 1:1 sitter, Family requests not to give Ativan, Patient’s daughter wants daily updates on her cell # 999-999-9999 etc.

If you can not finish any admission H&P, make sure all those unfinished patients are stable medically until the day team arrives.

Do some shifts in the day time if you never did to know how the system works in the day time so you can make better decisions.

Do not write very long H&P, write succinct notes covering all the pertinent points. Long H&Ps, waste time for day team and they may miss some critical point.

Always mention Family history or else your H&P may not qualify for the kind of billing you do.

Do not bill wrongly. If you put Observation order, bill for Observation code. If you put Admission order, bill for Admission code.

Make sure to put an end to IV fluids either in terms of amount or time. Do not place open orders for IV fluids. Assume that there is a chance that the day team hospitalist may not stop the iv fluids and patient gets fluid overloaded.

Based on the patient’s condition, mention what complication the next doctor can look for. For example, IV diuretics on a CKD patient. Mention in your Assessment and plan “Monitor kidney function closely”.

If one of the patients you admitted or if any other patient you were called about during the night, please inform the day time hospitalist about that sick  patient to see early.

Please write a small note in the chart if you have done something significant for the patient in the night. e.g. Patient had SOB during the night and you did CTA chest and found PE and started on Heparin. Just mention that in few lines in the chart.

A well made H&P is the proof of a quality nocturnist.

Ask for feedback from daytime hospitalist as they may hesitate to tell you for fear of making you upset. Take criticism professionally as we all can do mistakes and can learn from others.