Teacher-Learner Contract: Obstetrics Night Float Block

Teacher-Learner Contract: Obstetrics Night Float Block

MAHEC 3rd year Ob-Gyn Clerkship – Department of Obstetrics and Gynecology, Asheville, NC

Student Name: ______Rotation: ______

Instructions: The student should review this document with each resident-teacher on the team. Any changes to this document must be agreed to by all.

Inpatient Obstetrics: Labor and Delivery

CURRENT GOAL: Students assigned to the OB Night float block should attend daily evening rounds with the obstetrical team. The student will be assigned specific patients to follow. Students should contribute to the care of their assigned patients by performing labor and delivery rounds every 2 hours, writing progress notes in the medical record, and interpreting laboratory and imaging studies as directed by the supervising residents and faculty.

1. Where and when should the students report?

Evening rounds begin promptly at 5:45pm at the nurse’s station annex on Labor and Delivery, 4th floor. Students should be dressed in scrubs for L&D.

1. Who should the students report to – who assigns patients to the students?

The student should report to the chief resident primarily. The chief resident will likely assign the student to work alongside one of the first or second year residents. Possible patient care assignments include patients in Outpatient L&D for triage, patients scheduled for procedures, or laboring patients.

1. Should the student initially see patients by themselves and then present them to a resident, or should a resident see the patient along with the student?

The student should first evaluate assigned patients independently when their 2 hour note is due or when something acutely changes. The student should obtain a pertinent history and perform a focused physical exam (excluding pelvic or breast). The student should then report this data to the supervising resident who will then evaluate the patient with the student and confirm the history and physical exam findings, and also perform the pelvic exam if indicated. If the patient is in labor with an epidural, the student will likely be invited to perform a pelvic exam along with the resident.

1. Should the student write a progress note? If yes, who will review the student’s notes and provide feedback? Can this be consistently done prior to morning team rounds?

The student should write progress notes on assigned patients in the paper chart for laboring patients and should complete a procedure note when applicable. The supervising resident will review the note, co-sign if applicable, and should provide feedback.

1. What are the specific tasks that the students should complete on the patients that they see?

The student should only see assigned patients. The student should perform labor and delivery assessments, evaluate the patient every 2 hours, make sure all intrapartum goals are met, review and document all labs and imaging, and document their findings in the paper chart. The student should be prepared to present any patients he/she is following at morning board rounds.

1. What procedures should the student participate in?

If a patient the student has been following proceeds to delivery, the student will be expected to assist the nurses and observe during pushing. As delivery approaches, the student will be expected to scrub in for the procedure, and the level of participation will be determined by the supervising resident. Students will progress from observation, to delivery of placenta, then actual delivery of the baby.

1. Should the students complete any tasks on patients that they do not see? If yes, what?

The student’s first priority is his/her assigned patients. Once finished providing care for the assigned patients or when other learning opportunities are lacking, the student should review a pertinent topic in obstetrics using one of the online or print resources available to them.

Inpatient Obstetrics: Triage

CURRENT GOAL: Each evening, students may be assigned the responsibility of evaluating patients in the outpatient L&D triage area. Students should contribute to the care of these patients by performing assessments and formulating care plans under the direct supervision of residents and faculty. When possible, once an assigned patient is admitted for intrapartum or antepartum management, the student should continue following the patient through the duration of her intrapartum and postpartum course.

1. Where and when should the students report?

When a patient arrives at Ob triage, the patient will be assigned to the student by the Ob night float chief resident.

1. Should the student initially see patients by themselves and then present them to a resident, or should a resident see the patient along with the student?

The student should first evaluate the patient independently and generate a problem list based on the history and limited physical exam. The student should then report this data to the supervising resident who will then evaluate the patient with the student and confirm the history and physical exam findings, as well as perform the pelvic exam if

indicated. Depending on the acuity of the presenting symptoms, this system may be altered and the student will instead evaluate the patient alongside the resident.

1. Who will review the students’ evaluations of patients and provide feedback? Can this be consistently done?

The supervising resident will give immediate feedback to the student.

1. Should the student write a progress note? If yes, who will review the student’s notes and provide feedback?

If the patient is to be admitted, the student should assist in writing the H&P. If the patient is to be discharged, the students at this time do not have access to the Depart Process in Cerner and will not be able to write a note documenting the encounter. The student should verbally describe to the supervising resident what they would write in such a note.

1. What are the specific tasks that the students should complete on the patients that they see?

The student should complete the HPI, focused history, and pertinent ROS on their own. They should review vital signs, perform relevant physical exam (excluding pelvic exam), and review fetal heart rate tracing. The student should then synthesize this information and present it to the supervising resident.

1. Should the students complete any tasks on patients that they do not see? If yes, what?

The student’s first priority is his/her assigned patients. Once finished providing care for the assigned patients or when other learning opportunities are lacking, the student may assist in following up with laboratory and imaging studies for any obstetrical patient, or in providing counseling for common issues encountered in the Ob Triage area.

1. Are there any general tasks that the students can help the team with?

When other learning opportunities are lacking, the student may be asked to assist in preparation of discharge items such as patient instructions, prescriptions, etc.

Inpatient Obstetrics: Scheduled Procedures

CURRENT GOAL: Students will have the opportunity to participate in the perioperative care of patients scheduled for obstetrical procedures. These cases may occur at anytime during the day. The OB night float chief resident will assign cases in which the student will participate on the morning of the procedure. In general, most of these cases will be Cesarean sections.

1. Who assigns cases to the students? When should case assignment occur?

The OB night float chief resident will assign cases to the student at rounds.

1. What kinds of cases should the students expect to see?

The goal is for the student to see a breadth of surgical problems and techniques. The majority of cases will be Cesarean sections, but other cases include cerclage placement or removal, external cephalic version, and amniocentesis.

1. What role should the student have in the pre-op care of the patients?

The student should accompany the operating resident to the L&D pre-op area and meet his/her assigned patient prior to beginning the procedure.

1. What are the specific tasks that the students should complete on the patients when they are in the operating room?

The student should assure that a gown and surgical gloves are available for them by asking the scrub tech or circulator nurse prior to the procedure. The student may be asked to assist in tasks such as transferring the patient to the operating table, positioning the patient, and placement of a Foley catheter. In most cases, the student will scrub. Appropriate intraoperative tasks include holding retractors and cutting suture. For the surgically advanced student, appropriate tasks include delivery of the placenta, intraoperative artificial rupture of membranes, sewing peritoneum, sewing fascia, using Bovie for hemostasis in the subcutaneous fat, and sewing skin. The supervising resident or faculty member will decide if a student is prepared for these tasks. Students should be familiar with the patient’s history, diagnosis, and indication for surgery if the case is assigned in advance.

1. What should the students do when there are no cases in which they are able to participate?

The student should participate in care of patients in Outpatient L&D or who are laboring.

Inpatient Obstetrics: Unscheduled Procedures

CURRENT GOAL: Students will have the opportunity to participate in the perioperative care of patients who unexpectedly need to have a Cesarean section or other procedure. These cases may occur at anytime during the day. The OB night float chief resident will assign cases in which the student will participate as soon as the case has been confirmed.

1. Who assigns cases to the students? When should case assignment occur?

The OB night float chief resident will assign cases to the student when the need for procedure has been confirmed. If a student has been following a patient during their labor and the patient needs a Cesarean section, ideally the student would be assigned to the case.

Inpatient Obstetrics: Postpartum

CURRENT GOAL: Students assigned to the OB Night Float Block should attend daily rounds on postpartum patients or antepartum patients with the resident team. The student will be assigned specific patients to follow. Students should contribute to the care of their assigned patients by performing daily rounds, writing progress notes in the medical record, interpreting laboratory and imaging studies, and presenting those patients at team rounds.

1. Where and when should the students report?

The student should report to the Mother Baby Unit, G5, at 5:30 am each morning for post-partum rounds.

1. Who should the students report to – who assigns patients to the students?

Patient assignments will be given by the Ob days 2nd year. If that person is not available, the night float 2nd year will do the assignments.

1. Should the student initially see patients by themselves and then present them to a resident, or should a resident see the patient along with the student?

The student should first evaluate assigned patients independently. The student should obtain a pertinent history and perform a focused physical exam (excluding any breast or pelvic exams). The student should then report this data to the supervising resident who will then evaluate the patient with the student and confirm the history and physical exam findings, and also perform the pelvic exam if indicated. The student may assist the resident in removing bandages and/or drains only if specifically advised to do so.

1. Should the student write a progress note? If yes, who will review the student’s notes and provide feedback? Can this be consistently done prior to morning team rounds?

The student should write a progress note in the patient chart prior to presenting to the resident. The supervising resident will review the note and provide immediate feedback.

1. What are the specific tasks that the students should complete on the patients that they see?

The student should see the assigned patients on the post partum floor. The student should perform a post partum assessment, including daily evaluation of the patient before rounds, assessing whether or not post partum goals have been met, reviewing contraception desires of the patient, determining whether or not they are breast feeding, as well as follow-up and documentation of all labs and imaging studies in a standard SOAP note format.

1. Should the students complete any tasks on patients that they do not see? If yes, what?

The student’s first priority should always be his/her assigned patients. Once finished providing care for the assigned patients or when other learning opportunities are lacking, the student may be asked to assist in preparation of discharge items, such as patient instructions, prescriptions, etc.

1. Are there any general tasks that the students can help the team with?

On morning rounds, the student should take advantage of any opportunity to participate in patient counseling on issues such as breastfeeding, contraception, postpartum changes, etc.

General Guidelines

1. What should the students do when there are no learning opportunities in which they can participate (i.e. “downtime”)?

The student should use the time for self-study, but remain available.

1. Where should the students spend their down time?

The student can spend this time at the rounding table on L&D or in the doctor’s lounge on L&D. The student should always remain available by pager. The student should also remember to communicate with the Ob night float chief resident regarding his/her whereabouts at all times, including didactics, excused absences (as arranged with the clerkship director), and any other obligations.