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This thread is gonna be sexist and I pre-condemn and denounce myself. But anyone notice a difference in sign outs cross the gender divide? I feel like there is such a thing as a bro sign out. Probably because we tend to be used to dealing with our own gender more and continue to engage in bro speak with people in the same age bracket.

Conversely this must create a sort of boys club that sucks for the women folk.
 

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I don't think it's sexist, it's just innate. Certain men, in general, over minimize things. Not all, but it's a stereotype for a reason.
At the same time, of the people I see when I'm coming in, I eyeroll equally. For the dudes, it's usually because they're conservative ****heads. For the women, it's because I'll know about the patient's pet's vaccination status by the time report is done.
In general, the women I've worked with are more conservative with their workups. They have higher admit percentages too. This may not be a national fact, but it's true for me (I've seen the data).
OTOH, there's literature out there that women have better outcomes. I'm not sure the data is all that rock solid, but you'd be damned if you think I'm going to talk about it on social media.
 

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This thread is gonna be sexist and I pre-condemn and denounce myself. But anyone notice a difference in sign outs cross the gender divide? I feel like there is such a thing as a bro sign out. Probably because we tend to be used to dealing with our own gender more and continue to engage in bro speak with people in the same age bracket.

Conversely this must create a sort of boys club that sucks for the women folk.
Yes. The bro sign out is quick and to the point, lke it should be. Devoid of needless and arbitrary details. Is there another kind?




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WilcoWorld

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This thread is gonna be sexist and I pre-condemn and denounce myself. But anyone notice a difference in sign outs cross the gender divide? I feel like there is such a thing as a bro sign out. Probably because we tend to be used to dealing with our own gender more and continue to engage in bro speak with people in the same age bracket.

Conversely this must create a sort of boys club that sucks for the women folk.

I don't really notice a gender-based difference. However I am in academics, so the residents drive the sign out process.

There is one thing that has become clear from years of taking sign out - everybody in the world except me is practicing EM the wrong way.
 

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My favorite thing to do, is when the bro (or gal) is finished their presentation, I ask them one question: "Would you like to discharge the patient now, or would you like me to do it as soon as you leave?" The resulting blank stare is priceless.
You and I must have very similar practice styles. I am a big fan of the 15 minute length of stay for most level 4s, and *some* level 3s.
 
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GeneralVeers

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You and I must have very similar practice styles. I am a big fan of the 15 minute length of stay for most level 4s, and *some* level 3s.
I totally get defensive medicine, however I work with some docs who do absolutely ******ed workups! My first act when getting sign-out from them is cancelling all their pending orders, and starting over. Often I just discharge or admit the patient then and there. Took a sign out on a pregnant, 32 yo female with chest pain. He had ordered serial troponins on her!! Yeah I'm not keeping her an extra 2 hours for the 1:1,000,000 chance she might have a STEMI not picked up by the normal EKG or first troponin.
 
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I totally get defensive medicine, however I work with some docs who do absolutely ******ed workups! My first act when getting sign-out from them is cancelling all their pending orders, and starting over. Often I just discharge or admit the patient then and there. Took a sign out on a pregnant, 32 yo female with chest pain. He had ordered serial troponins on her!! Yeah I'm not keeping her an extra 2 hours for the 1:1,000,000 chance she might have a STEMI not picked up by the normal EKG or first troponin.
It's against bro code to sign out a patient who can be discharged!

As an aside, I almost never cancel an imaging or lab test ordered by the former doc even when I hate that it's been ordered. I feel like that would increase my liability if a bad outcome or miss occurs. "Dr did you really cancel this life saving diagnostic test? One that your colleague thought emergently necessary?"
 
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Yeah but overtesters who want to leave their **** for others to clean up can be annoying.

"This patient has upper abd pain, labs and U/S were negative but I'm just gonna get a quick CT and then they can go home if negative".
 
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@xaelia once dc'd a cardene drip on a patient and discharged them.

My favorite of all time was a guy who had fallen, negative CT, still had back pain, negative MRI, went back to CT and they saw "gallbladder wall thickening and enlargement" so they ordered an US, this was also negative. The signout was "I'm not sure if you want to get a HIDA scan or not".
Um, no. I'm not going to write a case report for the first traumatic cholecystitis ever. Best part, he didn't have abdominal pain.
 

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@xaelia once dc'd a cardene drip on a patient and discharged them.

My favorite of all time was a guy who had fallen, negative CT, still had back pain, negative MRI, went back to CT and they saw "gallbladder wall thickening and enlargement" so they ordered an US, this was also negative. The signout was "I'm not sure if you want to get a HIDA scan or not".
Um, no. I'm not going to write a case report for the first traumatic cholecystitis ever. Best part, he didn't have abdominal pain.

VOMIT... victim of medical imaging technology.
 
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It's against bro code to sign out a patient who can be discharged!

As an aside, I almost never cancel an imaging or lab test ordered by the former doc even when I hate that it's been ordered. I feel like that would increase my liability if a bad outcome or miss occurs. "Dr did you really cancel this life saving diagnostic test? One that your colleague thought emergently necessary?"
Agreed. It leaves you high and dry and already on the wrong side of "standard of care". Please don't cancel a test that I felt necessary and had already ordered. If you want to alter the dispo after reviewing the results or the patient himself wants to stop further testing or go home feel free to document and do so.
 

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True story.

Doc signout - "Pt looks fine, I am not sure what is wrong. But if the labs are fine, she can be discharged"

Me - Looked at vitals, pt tachy in the 130's, temp 104, hypotensive, 70ish female. Geeezzzz
Me - Went to check on her and she looks like poop.
Me - Looked at labs that just returned. WBC in the 20's, labs all out of wack
Me - Wondering WTF. Did she even look at this lady?

Yeah you can guess the gender.
 
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GeneralVeers

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Agreed. It leaves you high and dry and already on the wrong side of "standard of care". Please don't cancel a test that I felt necessary and had already ordered. If you want to alter the dispo after reviewing the results or the patient himself wants to stop further testing or go home feel free to document and do so.
Gotta disagree with you. Some of the people I work with are completely ******ed over-testers. Serial cardiac enzymes on a patient < 40 with no risk factors and negative EKG? CANCEL! Rapid Strep test.....ever? CANCEL! CT scan with PO contrast? CANCEL and replace with non-po.

I once got a sign out: "This 30 year old female has been vomiting. Her labs are normal except she has ketones in her urine. I want to order fluids, then get a repeat UA in 1 hour. She should be good to go home if the ketones are gone". You better believe I discharged that one the second she (the other doctor) left.
 
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I don't like changing someone else's plan to a less conservative route.

I will go the other way and admit people they thought could go home.

If I really think their plan is crazy, I'll try to get them to dispo the patient.

I worked with one doc who had some of the craziest plans I've ever encountered.
Fortunately, he retired.
 

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Gotta disagree with you. Some of the people I work with are completely ******ed over-testers. Serial cardiac enzymes on a patient < 40 with no risk factors and negative EKG? CANCEL! Rapid Strep test.....ever? CANCEL! CT scan with PO contrast? CANCEL and replace with non-po.

I once got a sign out: "This 30 year old female has been vomiting. Her labs are normal except she has ketones in her urine. I want to order fluids, then get a repeat UA in 1 hour. She should be good to go home if the ketones are gone". You better believe I discharged that one the second she (the other doctor) left.
That. Is. ******ed.
 
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My favorite thing to do, is when the bro (or gal) is finished their presentation, I ask them one question: "Would you like to discharge the patient now, or would you like me to do it as soon as you leave?" The resulting blank stare is priceless.
I feel your pain but if this is really your favorite thing to do and you do it often (or really ever), I really think you'd earn a reputation of being an uncollegial jerk.

The bro thing to do would be to wait for the doctor to go home and then discharge the patient without such a confrontation with your peer.

But in any case I just go see other patients and wait till the test comes back. For the reason listed above, I.e. Increased liability. Although I do make sure to eyeball the patient first.
 
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Yeah but overtesters who want to leave their **** for others to clean up can be annoying.

"This patient has upper abd pain, labs and U/S were negative but I'm just gonna get a quick CT and then they can go home if negative".
"If this sepsis workup and CT are negative, have him seen by mental health for psychosis. Afebrile with normal vitals. Police we're called because he was barricaded in his house paranoid people were trying to kill him. He's had episodes of psychosis in the past."

Me (brand new out of residency taking sign out): "Okay, sounds great."
 
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"If this sepsis workup and CT are negative, have him seen by mental health for psychosis. Afebrile with normal vitals. Police we're called because he was barricaded in his house paranoid people were trying to kill him. He's had episodes of psychosis in the past."

Me (brand new out of residency taking sign out): "Okay, sounds great."
I say sounds great to any sign out aside from signing out procedures, rectal or pelvic exams.
 
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Wow, I just recently got at my shop but sign out here is discouraged. People finish most of what they have to do and if there is sign out the patients ready to spell but you're just keeping an eye on the patient until they go upstairs.

do you even get paid on your sign out patients?
 

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@xaelia once dc'd a cardene drip on a patient and discharged them.
Sign-out: I've got this asthmatic with wheezing where the triage lactate came back elevated ... I've just been giving her fluids and repeating nebs and <7 hours later> repeating the lactate but it keeps staying elevated.

Me: When your name comes off the patient and my name goes on, I'm going to hit the button that sets her free.
 

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Sign-out: I've got this asthmatic with wheezing where the triage lactate came back elevated ... I've just been giving her fluids and repeating nebs and <7 hours later> repeating the lactate but it keeps staying elevated.

Me: When your name comes off the patient and my name goes on, I'm going to hit the button that sets her free.
This might be the sort of question that you could answer: What % of US health care expenditures could be safely reduced by eliminating the triage lactate and its downstream unnecessary tests and treatment?

When I trained, we checked lactate on patients who were in septic shock so we could monitor their resuscitation. Now I see people checking lactate on patients "to see if they're sick."
 
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Wow, I just recently got at my shop but sign out here is discouraged. People finish most of what they have to do and if there is sign out the patients ready to spell but you're just keeping an eye on the patient until they go upstairs.

do you even get paid on your sign out patients?
There seem to be two different cultures at different shops. One that says "just sign out and leave", which is how it was in my residency. And the other, which I think is more common in the community setting, is to only sign out minimally.

When I switched to the latter it was a shock and I hated it. But then I realized after a month or two that I could optimize my work and get out on time. This involved yelling at people to get CTs done 2 hours before sign out, and having a higher threshold for any imaging after that. And near the end I'm cherry picking patients.

If it was routine to stay past an hour at a shop and I couldn't figure out how to get out on time, then I'd leave that shop. In retrospect this is something to find out before you sign on.

And no I don't think you usually get paid for staying overtime. This would encourage and reward disorganized and slow docs.
 
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Took a sign out on a pregnant, 32 yo female with chest pain. He had ordered serial troponins on her!! Yeah I'm not keeping her an extra 2 hours for the 1:1,000,000 chance she might have a STEMI not picked up by the normal EKG or first troponin.
I learned a lesson very early on my 1st EM rotation. Presenting a similar patient: "I'd get CBC, CMP, Cardiac Enzymes X3". Attending stops me: "Whoa, Whoa, Whoa, Times 3? You think she's going to stay here that long? Nope, get one set. If it's positive, Cardiology does the rest on the floor."
 

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On night shift particularly there is a trend toward a rush of folks checking in and ambulances coming very early in the am. Not nearly enough time to see them all to conclusion wo staying late. As a group we have decided to go the route of the leaving doc (usually the overnight) to just do an RME/PIT type exam to stop the clock, glad hand the pt and family and just order minimal/nothing and let them know the am doc will be in shortly.
If sick then we intervene as needed.
Sign outs are: "RMEd this one, stable" or "this ones sick with xyz, go check them out first, gave meds..."
Much nicer this way.
 
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Sign outs are: "RMEd this one, stable" or "this ones sick with xyz, go check them out first, gave meds..."
Much nicer this way.
I agree with this. In general, night shifters, and docs on 12 hour shifts get to go home on time and can sign out anything. If you are on an 8-10 hour shift, and have overlap with the oncoming physician, then there shouldn't be many or any sign-outs.
 

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Gotta disagree with you. Some of the people I work with are completely ******ed over-testers. Serial cardiac enzymes on a patient < 40 with no risk factors and negative EKG? CANCEL! Rapid Strep test.....ever? CANCEL! CT scan with PO contrast? CANCEL and replace with non-po.

I once got a sign out: "This 30 year old female has been vomiting. Her labs are normal except she has ketones in her urine. I want to order fluids, then get a repeat UA in 1 hour. She should be good to go home if the ketones are gone". You better believe I discharged that one the second she (the other doctor) left.
we all disagree with others management. Im just too lazy to change conservative docs ways. If they r not hurting the pts, they can order whatever they want. Im going to see the new patients that are stacked high.

Our PAs get bent out of shape b/c they have no clue what to do b/c all attendings do something different. I just tell them not to kill the pt and chart like they are spry 20 yr olds if discharged.
 

WilcoWorld

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On night shift particularly there is a trend toward a rush of folks checking in and ambulances coming very early in the am. Not nearly enough time to see them all to conclusion wo staying late. As a group we have decided to go the route of the leaving doc (usually the overnight) to just do an RME/PIT type exam to stop the clock, glad hand the pt and family and just order minimal/nothing and let them know the am doc will be in shortly.
If sick then we intervene as needed.
Sign outs are: "RMEd this one, stable" or "this ones sick with xyz, go check them out first, gave meds..."
Much nicer this way.
This can be abused, but it's generally a good policy.
In departments where everyone works nights, more people understand that helping the overnight crew GTFO is good all around.

That said, it sounds like your group is understaffing the early AM - likely to keep the # of overnight shifts down. Any possibility of adding an early AM shift instead?
 

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I totally get defensive medicine, however I work with some docs who do absolutely ******ed workups! My first act when getting sign-out from them is cancelling all their pending orders, and starting over. Often I just discharge or admit the patient then and there. Took a sign out on a pregnant, 32 yo female with chest pain. He had ordered serial troponins on her!! Yeah I'm not keeping her an extra 2 hours for the 1:1,000,000 chance she might have a STEMI not picked up by the normal EKG or first troponin.
Ionno man, I treat it as a numbers game. I see 20-30 patients a shift and work 15-18 shifts a month. Over the span of a year, if you're consistently taking a 1/1mil chances of a bad outcome than the chances you're going to have a bad outcome at some point are a lot smaller. In your case, if there's a bad outcome and you only had 1 trop/ekg I think it's pretty easy to get hosed. You'll still probably get hosed if there's a bad outcome and you had repeat EKG/trop which were negative. I think at the end of the day, everyone has bad outcomes and misses. You'd probably have less of them if you order more. Things come down to how you document your MDM and how badly the patient and their family wants to sue you. "The doctor spent 10 minutes and said all the tests were fine and it was just anxiety" doesn't portend well when you have your freak 32yo keels over and die from their MI. I don't know about you, but I have mouths to feed. Sally Mae and Frannie Mack being two of them. I'm fine with keeping someone from their day for an extra hour to put something in the chart that mitigates my risk, prevents headaches and keeps food on the table.
 
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GeneralVeers

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Ionno man, I treat it as a numbers game. I see 20-30 patients a shift and work 15-18 shifts a month. Over the span of a year, if you're consistently taking a 1/1mil chances of a bad outcome than the chances you're going to have a bad outcome at some point are a lot smaller. In your case, if there's a bad outcome and you only had 1 trop/ekg I think it's pretty easy to get hosed. You'll still probably get hosed if there's a bad outcome and you had repeat EKG/trop which were negative. I think at the end of the day, everyone has bad outcomes and misses. You'd probably have less of them if you order more. Things come down to how you document your MDM and how badly the patient and their family wants to sue you. "The doctor spent 10 minutes and said all the tests were fine and it was just anxiety" doesn't portend well when you have your freak 32yo keels over and die from their MI. I don't know about you, but I have mouths to feed. Sally Mae and Frannie Mack being two of them. I'm fine with keeping someone from their day for an extra hour to put something in the chart that mitigates my risk, prevents headaches and keeps food on the table.
I don't beat my head against the wall for 1:1,000,000 incidence of disease. At some point we will all miss something regardless of our ordering patterns.
 

GeneralVeers

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we all disagree with others management. Im just too lazy to change conservative docs ways. If they r not hurting the pts, they can order whatever they want. Im going to see the new patients that are stacked high.

Our PAs get bent out of shape b/c they have no clue what to do b/c all attendings do something different. I just tell them not to kill the pt and chart like they are spry 20 yr olds if discharged.
I agree to an extent. If the department is empty, then I generally don't interfere unless it's a potentially harmful CT the patient doesn't need.

If the department is packed, and I have unseen patients waiting in the lobby and there are no rooms available, I will try to shorten the workup of the sign-out patients as much as possible to either get them discharged or admitted.
 

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Luckily I'm in an RVU model. I love the sign outs. Give them all to me. I get up immediately and start over with all of them but I document "transition of care" on every single one and they all go towards my productivity. The only ones that are annoying are the pelvic sign outs. I've got this night doc that has signed out two to me in the last month. I even asked him point blank "Dude...you're not signing out a pelvic to me are you?" "Noway man, no GU complaints at all". Yeah right...

And for the love of God please don't save a 2 hour lac repair until the end of your shift and then try to sign that out to me. Not happenin....
 
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GeneralVeers

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And for the love of God please don't save a 2 hour lac repair until the end of your shift and then try to sign that out to me. Not happenin....
As a night shift doc it's a trade-off. The other night I had 13 people check in during the last 3 hours of my shift. Do I see everyone and get workups started, or do procedures? If I do a 2-hour lac repair, that means 5-6 people aren't getting seen or having workups started. Would you rather I greet all the patients, get a chart and workup started and sign out the lac repair, or do you want to see patients that have been waiting 2-3 hours while I repair a lac and take a hit on your door-to-doc times?
 

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And most places you'll probably have some mlp/resident/med student in the morning to take care of it for you. I can't even remember the last time I had to do a lac repair by myself ...


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As a night shift doc it's a trade-off. The other night I had 13 people check in during the last 3 hours of my shift. Do I see everyone and get workups started, or do procedures? If I do a 2-hour lac repair, that means 5-6 people aren't getting seen or having workups started. Would you rather I greet all the patients, get a chart and workup started and sign out the lac repair, or do you want to see patients that have been waiting 2-3 hours while I repair a lac and take a hit on your door-to-doc times?
Look, I do nights too and I never sign out pelvics or time intensive procedures. Do you sign out LPs too or central lines? Yet, I find some way to see the pt's in the waiting room and keep the cogs turning in the ED overnight. There's always extenuating circumstances that impact metrics but it never ceases to amaze me at the lengths some people will go to in order to get out of pelvics, lac repairs, disempactions and the countless other undesired and time consuming procedures that they perceive as preventing them from leaving on time. Sometimes, you have to stay a little bit after your shift to wrap things up and that's just the nature of this business. Your colleagues will respect you for it.

In our shop, there's really no reason for it as you have an hour overlap between the night and am doc that gives you time to wind down, wrap up your pt's, sign out the ones that will be there awhile and finish your charting. That should leave plenty of time for a lac repair or hell, get an MLP to do it.
 

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In our shop, there's really no reason for it as you have an hour overlap between the night and am doc that gives you time to wind down, wrap up your pt's, sign out the ones that will be there awhile and finish your charting. That should leave plenty of time for a lac repair or hell, get an MLP to do it.
There is no overlap unfortunately at my shops. Equating an LP and central line (potentially life-saving) with a lac repair or pelvic is not appropriate. Again it's a trade-off. With no overlap, there is always going to be sign-out of some sort. Procedures, or angry, waiting patients?
 

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There is no overlap unfortunately at my shops. Equating an LP and central line (potentially life-saving) with a lac repair or pelvic is not appropriate. Again it's a trade-off. With no overlap, there is always going to be sign-out of some sort. Procedures, or angry, waiting patients?
I agree that central line =/= lac repair, but you just slipped signing out a pelvic into that argument. Do you actually sign out parts of your physical exam?
 
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I agree that central line =/= lac repair, but you just slipped signing out a pelvic into that argument. Do you actually sign out parts of your physical exam?
It depends. If I have nothing else to do and am caught up I can do that. Pelvics are not easy as far as it typically takes my nurses 30 minutes to get set-up and find equipment and get the patient into a gown and positioned (yep they are that bad!). If I have a ton of patients left over at end of shift, I'd rather use the time to dispo patients and not sign them out, than do an exam. Being single coverage night shift with no overlap, I am going home at the end of my shift. I am not on strict RVUs, so am not really paid for staying late.
 

GeneralVeers

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Attending Physician
It depends. If I have nothing else to do and am caught up I can do that. Pelvics are not easy as far as it typically takes my nurses 30 minutes to get set-up and find equipment and get the patient into a gown and positioned (yep they are that bad!). If I have a ton of patients left over at end of shift, I'd rather use the time to dispo patients and not sign them out, than do an exam. Being single coverage night shift with no overlap, I am going home at the end of my shift. I am not on strict RVUs, so am not really paid for staying late.
It is rare to sign out such a thing. If I am that busy in the last hour of my shift, I probably won't see the patient and start anything anway as I will be too busy trying to disposition as many of the completed patients as I can. They will be a "new" patient for the oncoming.
 
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