Your first admission:
workflow and prioritization

Why this session

Ask residents what they most wished they had in July and the answers are not diseases — they are prioritization, task management, and a way to keep the day from happening to them; the surveys behind this curriculum say the same thing from program directors’ side (the evidence). The admission is where all of it collides: a new patient, a full list, a clock, and a phone that keeps ringing. Sequencing is the skill, and it is teachable on paper before it is tested in a hallway.

What interns leave able to do

1. Accept an admission with the right questions answered: acuity and trajectory, what’s been done, what’s pending, code status, isolation.
2. Triage competing admissions and tasks: sick → time-critical → routine.
3. Run an efficient admission workflow: focused chart review → bedside → time-critical orders → note.
4. Perform a medication reconciliation that does not copy forward someone else’s errors.
5. Ask the senior for help early and specifically.

The case

Disclosed one part at a time; interns commit before each reveal.

Running the room

Part 1 — accepting the admission

The sixty-second script, boarded as the room generates it:

• The one-liner and the actual admitting diagnosis — not “needs a bed.”
• Current vitals and trajectory. Not “stable” — “what are they now, and what were they an hour ago?”
• What has been done: cultures, antibiotics, fluids given and the response, and every pending test you are about to inherit.
• Code status — ask every time, before the patient leaves the ED. Awkward beats absent.
• Isolation needs — bed placement depends on it.
• “Anything you’re worried about that hasn’t been addressed?” The ED’s gestalt should transfer with the patient.

Triage: Bed A first. Fever, confusion, tachycardia, and a soft pressure after a liter is sepsis until proven otherwise, and sepsis antibiotics are a genuinely time-critical order — the Surviving Sepsis Campaign builds its recommendations around the first hour for exactly this situation.¹ Bed B is pain-free with negative biomarkers; he waits safely — and you confirm the ED will re-page if anything changes, because a waiting patient still needs an owner with eyes.

Part 2 — the workflow

1. Bedside before orders for anyone not clearly stable. See her, examine her, form your own impression — the ED’s data are a head start, not a substitute. And ask the level-of-care question now: persistent hypotension or a rising lactate is a stepdown-or-ICU conversation before she crashes on the floor, not after.
2. Time-critical orders from the bedside or the nearest computer: antibiotics — allergies checked, renally dosed; fluids with reassessment parameters; vitals frequency; and give the nurse your trigger list out loud: “call me if the systolic drops under 100 or her mental status is worse.”
3. The order-set skeleton: admit to and attending, diagnosis, condition, vitals, activity, diet, nursing parameters, code status, VTE prophylaxis, labs, medications. Order sets are checklists — use them, then think: which defaults are wrong for this patient?
4. Medication reconciliation is the highest-yield safety task of the admission — a procedure, not clerical work:
   • Two sources when you can get them: the daughter plus the pharmacy fill history plus the facility’s medication list. A phoned-in “I think” list is a starting point, not a reconciliation.
   • The blood thinner is the landmine: unknown agent, unknown indication and duration, renal function pending — and urosepsis with possible AKI changes every dosing decision. This is precisely what the senior and the pharmacist are for.
   • Home insulin is a decision, not a default: is she eating? Her home glargine dose is not automatically her inpatient dose.
   • Hold the lisinopril in sepsis with soft pressures; decide the metoprolol on her hemodynamics. Every home medication is a choice you are making, whether you notice or not.
5. The note comes last for a sick patient. A skeleton H&P — one-liner, HPI bullets, medication list flagged preliminary, plan bullets — beats a polished note started at 6 p.m. on a patient whose antibiotics went in at 5.

Part 3 — the live sequencing exercise

Put the five items on the whiteboard — seven notes, the potassium of 5.9, the family update, Bed B, sign-out — and have the group physically order them and defend the order. The reasoning to draw out:

• The potassium first. Hyperkalemia is the silent killer on the list: confirm it’s real, get an ECG, treat per your protocol, recheck. Minutes of work; it outranks everything else on the board.
• Bed B next — two hours waited, verifiably stable: a focused twenty-minute admission with safety orders and a skeleton note. The two pages mean the ED is anxious; thirty seconds of “on my way, fifteen minutes” defuses more than an apology later.
• The family update: five focused minutes by phone — or a specific promised time (“after sign-out, by 6:30”), kept. Scheduled beats interrupted.
• Notes: skeletons during the afternoon, completion after sign-out. Documentation is real work, and it is routine work — it never outranks a sick patient, a critical value, or a safe handoff.
• Sign-out: arrive with the if/then list already built — “Bed A: watcher; if the systolic drops under 100 after fluids, call the rapid response. The potassium patient: recheck posts at 6; if it’s still up, re-treat per protocol.” A good sign-out is how you delegate safely — the handoff session is the technique.
• The senior call, scripted: “I’m drowning” is not a call. “I have seven notes, an unfinished admission, and a hyperkalemia I’m treating — can you take Bed B’s H&P?” is. Asking for help with a specific task is what competence sounds like in July.

Common pitfalls to surface

• Chart-review paralysis: thirty minutes reading before ever seeing the patient.
• Copy-forward medication lists — last admission’s doses, the anticoagulant nobody restarted, or restarted twice.
• Note-writing while a septic patient waits.
• Suffering silently until 9 p.m., then calling the senior who could have fixed it at 4.
• “Stable” accepted as a diagnosis.

Key teaching points

1. Sick → time-critical → routine. In that order, always — even when routine is more satisfying.
2. “Stable” is a trend, not a word. Verify with numbers and trajectory before you prioritize away from a patient.
3. Medication reconciliation is a safety procedure. Two sources; anticoagulants and insulin get your full attention.
4. Bedside before orders; antibiotics before notes.
5. Ask for help early and specifically — “take Bed B,” not “I’m overwhelmed.”

Pocket card

Variations

• The third call. Mid-exercise, add an 86-year-old on warfarin who fell, head CT pending — and force a live re-triage of the whole board.
• The experienced-cohort version. For a group already on the wards, replace Part 1 with a real, de-identified admission from the chief’s own recent week — and let the room critique what actually happened.

Notes

The case is a fictional composite; no patient in it is real. The evidence for why prioritization and task management anchor an intern bootcamp is in the bootcamp introduction.

Sources

1. Prescott, H. C., Antonelli, M., Alhazzani, W., Møller, M. H., Alshamsi, F., Azevedo, L. C. P., Belley-Cote, E., De Waele, J., Derde, L., Dionne, J. C., Evans, L., Gershengorn, H. B., Hodgson, C. L., Honarmand, K., … (2026). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Critical Care Medicine, 54(4), 725–812. https://pubmed.ncbi.nlm.nih.gov/41869847/ Supersedes the 2021 edition; the Campaign revises periodically, so confirm the current edition before teaching. ↩

This page is a teaching scenario for facilitated small-group education. Every patient in it is fictional. It is not clinical guidance for the care of any actual patient, and it does not replace your hospital’s protocols, order sets, or escalation pathways — localize before teaching. Last reviewed July 2026.