Internal and Hospital Medicine

01Purpose and scope

• This manual supports the course Internal and Hospital Medicine. It describes how general internists and hospitalists manage adult patients admitted with medical problems, from the emergency department handoff through discharge and follow-up.
• The scope covers daily work on inpatient medical services: admission assessment, problem-based rounds, consultation requests, medication management, discharge planning, and communication with patients, families, and outside clinicians. It does not cover operative care, detailed intensive care decision-making, or pediatric practice, which have their own pathways and specialists.
• Practice varies by hospital size, teaching status, staffing model, and local protocols. A community hospital with one hospitalist group may run rounds differently from an academic center with resident teams. This guidance does not replace qualified professional judgment, approved hospital procedures, or the credentialing and privileges required to practice at a given facility.

02Core principles

• Patient problems drive the structure of care. Each active problem should have a current assessment, a working plan, and a named owner, even when the patient has many diagnoses. A problem list that carries forward unchanged for several days usually means nobody has rechecked it.
• Safety is built into routine steps rather than left to memory. Two identifiers before procedures and medications, a reconciled medication list at admission and transfer, and a clear code status are examples. Hospitals rely on these habits because inpatients change quickly.
• Diagnosis stays provisional until the data support it. Hospitalists keep a differential open, note what would change their mind, and avoid anchoring on the first label written in the emergency department.
• Discharge planning begins on admission. The team that thinks early about what the patient needs at home, such as medications they can afford, transportation, and a follow-up appointment, prevents many avoidable returns.

03Planning and preparation

• Before a shift, review the census, pending results, consults awaiting response, and patients flagged for discharge that day. Many hospitals use a sign-out tool or electronic dashboard for this. The content matters more than the format.
• Confirm the admitting diagnosis, the reason for admission, code status, allergies, and the healthcare proxy. For transfers from other units or facilities, obtain outside records and a home medication list from more than one source where possible, since patients often do not recall doses accurately.
• Decide what must happen today. This usually means choosing two or three goals, such as deciding on an antibiotic course, arranging home oxygen, or starting a social work assessment. A plan without priorities tends to stall.
• Know your resources: pharmacy, respiratory therapy, case management, physical and occupational therapy, nutrition, palliative care, and the rapid response or escalation pathway. Learn who answers the phone at night and what the hospital expects for escalation.

04Recommended workflow

1. 1
   : Admission assessment. Take a history, perform an examination, review prior records, and write an admission note that states working diagnoses, the plan for each problem, and the expected length of stay. Document why the patient needs hospital level care, since utilization reviewers and payers will ask.
2. 2
   : Initial orders and safety review. Order labs, imaging, and monitoring that answer specific questions. Complete medication reconciliation, decide which home medications to continue, hold, or stop, and set venous thromboembolism prophylaxis and diet orders with stated reasons.
3. 3
   : Daily rounds. For each patient, review overnight events, vital sign trends, intake and output, labs, and imaging. Examine the patient, update the problem list, and state a plan for each active problem along with the condition that would stop or change therapy.
4. 4
   : Consultation and communication. Write specific consult questions instead of a general request to see the patient. Speak with consultants directly for urgent or conflicting recommendations, and record agreed plans in the chart.
5. 5
   : Medication management. Review each active order for indication, dose adjustment for kidney or liver function, interactions, and stop dates for antibiotics and anticoagulants. Ask pharmacy to check renal dosing whenever creatinine changes.
6. 6
   : Discharge planning. Identify discharge criteria early, confirm the patient can take medications safely, arrange follow-up with named clinicians and time frames, and send the summary to the primary care clinician on or before the day of discharge where the system allows.
7. 7
   : Handoff. At shift change, give a structured verbal handoff such as SBAR or I-PASS, covering illness severity, pending items, contingency plans, and code status. Confirm the receiving clinician has read the note.

05Quality checks, risk controls and compliance

• Build checks into the daily routine. Examples include reviewing lines, catheters, and tubes each day with a stated removal plan, reviewing anticoagulation and insulin orders, and confirming that critical results have been acknowledged and acted upon.
• Know the high-risk areas: sepsis recognition, opioid and sedative use, anticoagulation, insulin, electrolyte replacement, and delirium. Many hospitals maintain protocols or order sets for these. Use them, and document when you depart from them and why.
• Compliance differs by country, state, and accrediting body. In the United States, privacy obligations under HIPAA, medical staff bylaws, and accreditation standards shape documentation and handoffs. Check the current authoritative source and your hospital policy rather than relying on this summary.
• Clinical decisions in this field carry direct risk to patients. This guidance does not replace qualified professional judgment, approved clinical protocols, or the authorization needed to order specific treatments or procedures at your facility.

06Collaboration and documentation

• Hospital medicine depends on nursing, pharmacy, therapy, case management, and the patient's primary clinician. Speak with the bedside nurse at least once a day about the plan, what they are watching for, and what should prompt a call.
• Notes should be readable by the next clinician. Record the reasoning behind decisions, not only the result. A progress note that says the antibiotic was changed to ceftriaxone, with no explanation, leaves the next team guessing about the culture data behind the change.
• Documentation also supports billing and quality review, but accuracy matters more than wording chosen to support a higher level of service. Copy-forward text can carry errors into new notes, so review and edit it every day.
• Share the discharge summary with the outpatient clinician and tell the patient what changed. Teach-back, where the patient restates instructions in their own words, is a practical check that the message landed.

07Measures and continuous improvement

• Track indicators that reflect the work: time from admission to first physician assessment, percentage of admissions with completed medication reconciliation, percentage of discharges with a documented follow-up appointment, readmissions within a defined window, and hospital-acquired harms such as falls, catheter infections, and pressure injuries.
• Use data with care. Small units produce noisy rates, and one patient can shift a percentage considerably. Look at trends across several reporting periods rather than a single snapshot, and pair the numbers with case review.
• Improvement work is usually modest: a revised discharge checklist, a standard order set for COPD exacerbations, or a daily huddle focused on lines and catheters. Test changes on one unit before spreading them, and measure whether they worked.
• Trade-offs are real. Tight length-of-stay targets can push discharges before patients are ready, while extensive testing adds cost and can cause harm. Set targets with clinical and operational leaders, and review outcomes as well as throughput.

08Common mistakes and how to prevent them

• Copy-forward errors occur when yesterday's plan carries into today without review. Prevent this by requiring a short daily reassessment of each problem and deleting outdated text.
• Diagnostic momentum keeps the first working diagnosis in place even as new results contradict it. Prevent this by writing down which finding would change your diagnosis and checking for it on rounds.
• Orphaned medications continue without an indication or stop date, especially antibiotics, anticoagulants, and opioids. Prevent this by requiring an indication and duration on each order and reviewing the active list at every rounds.
• Late discharge planning leaves home oxygen, prescriptions, or home health arrangements until the afternoon of discharge. Prevent this by flagging barriers on admission and reviewing them with case management early.
• Incomplete handoffs leave the receiving clinician unaware of pending results or of what to do if the patient worsens. Prevent this with a structured handoff and a written contingency plan.

09Practical checklist

• Confirm identity, code status, allergies, and healthcare proxy on admission.
• Reconcile home medications with at least two sources where possible.
• Write a problem-based assessment with a stated plan and owner for each problem.
• Review all active orders for indication, dose, and stop date each day.
• Review lines, catheters, and tubes and document removal plans.
• Confirm pending results and assign who will follow each one.
• Start discharge planning on admission and flag barriers early.
• Send the discharge summary and confirm follow-up with the outpatient clinician.
• Give a structured handoff at shift change that includes contingency plans.
• Check that local protocols and current authoritative guidance apply to your setting.

★Learning sources

• Micro Degree: Internal and Hospital Medicine
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support