Patients' Charts Should Come w/ User Manuals!

Today was my first day of Internal Medicine (IM) and it was overwhelming to say the least. I seriously was given a list of patients to see and told "go!" No resident or physician to tell me what to do; only my two fellow classmates to instruct me on what they thought they knew.

I literally saw my first patient ever today. I was so scared! I have had practice with fake (actors) patients but never a real-live sick one. It was definitely a first for me. I attempted to read up on the chart, then proceeded into the room to speak with the patient and her husband. They were very nice and helpful (besides the lady being agitated a having to sit up).

I really don't think they had any idea how nervous I was! But, I got a quick history and did a small physical and attempted to write my progress note. I hadn't done a SOAP note since April and had to dig deep to remember what the components were. Furthermore, the notes that I had been taught were around 5-7 pages long and there was no way that this was going to fly. I got the note down to one page, but whether I included the pertinent information is questionable. I certainly hope that I get some feedback on my notes (especially for my assessment and plan) so that I know what is actually expected of me.

To add onto the stress the attending asked if I could dictate a Discharge Note for her. Ha! I fumbled my way through the chart and started to attempt to dictate when I realized that I was pressing the play button when I wanted to pause and the pause button when I wanted to play. Ugh. Then, I got really confused since I couldn't see the physician signed copy of the meds that the patient was to go home with, so I ended up stopping the dictation completely. I had asked somebody around me if there was a sheet that I had neglected to see and he didn't see the correct form either and my attending was no where to be seen. Luckily the patient isn't going to be discharged until tomorrow and I was told that I could do the dictation tomorrow if I wished. And I definitely wish to do it tomorrow! After I discuss the med sheet with the doctor.

I feel like I am feeling around in the dark really having no idea how this world in the hospital works. Eek! :O