Intern Survival Guide Topic

Run the day before it runs you.

A prerounding script and time budget, task triage and batching, I-PASS handoffs and the evidence behind them, pages that get answered, the always-call-your-senior list, and the 2026 ACGME work-hour rules.

Reviewed October 2026 · verify against current guidelines

Day One · 1 of 6

Preround with a script.

The goal

Walk into rounds knowing what changed overnight for every patient, with a plan you can defend. Budget about 10 minutes for a stable established patient and 15–20 for a new or sick one, then work backward from when rounds start. Eight patients is roughly 90 minutes plus a buffer. These are working targets, not rules; they shrink fast.

Per patient, in this order

Overnight events	Sign-out, cross-cover and nursing notes. Anything that triggered a call.
Vitals	Tmax, trends, O₂ requirement, I/O, weight. Ranges, not single values.
Labs & micro	New results against yesterday's. Culture updates, drug levels, anything pending.
Imaging & consults	Final reads and new recommendations.
MAR	What was actually given. Held doses, refusals, and how many PRNs were used.
Lines, tubes, monitors	Central line, Foley, telemetry: does each still need to be there?
The patient	Ask how they are, do a focused exam, and find out what they want to know today.

See the patient before you present — Data on a screen is not a preround. Two minutes at the bedside catches what the chart misses.

Tmax maximum temperature in 24 hoursI/O intake and outputMAR medication administration recordPRN as-needed medication

Day One · 2 of 6

Triage the list like a patient.

Sort every task

Now	An unstable patient, a critical value, a nurse worried about a patient, a time-critical medication such as antibiotics for suspected sepsis.
Today, time-bound	Anything blocking a discharge: med rec, discharge orders, prescriptions, the summary. Consult calls that need a same-day answer.
Today, flexible	Progress notes, non-urgent follow-ups, routine order cleanup.
Batch	Family updates, outside-record requests, lab follow-ups you can check in one pass.

Batching that works

Discharges first. A discharge done early frees a bed, a nurse and your afternoon. The note can wait an hour; the discharge cannot.
Place consult calls right after rounds so answers come back the same day.
Enter orders in one pass per patient, then review them all once.
Set timed reminders for results (“recheck K at 14:00”) instead of refreshing the chart.
Keep one list with checkboxes and times. Not three sticky notes.
Write notes in blocks once the urgent work is done.

Day One · 3 of 6

Hand off with I-PASS.

The evidence

Starmer et al. (NEJM 2014) studied an I-PASS handoff program in nine pediatric residency programs across 10,740 admissions. The medical-error rate fell 23% (24.5 to 18.8 per 100 admissions) and preventable adverse events fell 30% (4.7 to 3.3 per 100 admissions). Nonpreventable adverse events did not change. Oral handoffs took no longer (2.4 vs 2.5 minutes per patient), and resident workflow did not change. The ACGME also requires structured, monitored hand-off processes (CPR 6.19.a).

I-PASS

I · Illness severity	Stable, watcher, or unstable. Say it first.
P · Patient summary	One-liner, reason for admission, hospital course, ongoing assessment, plan.
A · Action list	To-dos with a time and an owner. “Check 22:00 lactate; you own it.”
S · Situation awareness & contingency planning	What is going on, and what to do if it changes: “If…, then…”
S · Synthesis by receiver	The receiver summarizes, asks questions and restates the action items.

Contingencies worth handing off

“If her SBP drops below 90, see her, give a 500 mL bolus and recheck; if she doesn't respond, call the ICU and me.”
“If he spikes, blood cultures ×2; he's already on cefepime. If he's also hypotensive, treat it as sepsis and call a rapid response.”
“Family may call tonight. Code status is DNR/DNI, confirmed today with his daughter.”

Synthesis is not optional — If the receiver cannot read back the illness severity and the action list, the handoff has not happened.

I-PASS illness severity, patient summary, action list, situation awareness and contingency planning, synthesis by receiverCPR ACGME Common Program RequirementsSBP systolic blood pressureDNR/DNI do not resuscitate / do not intubate

Day One · 4 of 6

Page like you want to be paged.

A complete page

Who	Your name, role and a callback number that will reach you.
Patient	Name, room and a second identifier. Joint Commission goals require at least two identifiers; a room number is not one.
Urgency	Say it plainly: emergent, urgent within 15 minutes, or routine.
What	One line on what is happening.
The ask	What you need from them.

Weak vs strong

Weak: “Call 4-1234.”
Strong: “Intern on 5 West, 4-1234. Rm 512, Jane Doe, MRN ending 4471. K 6.1 on AM labs, non-hemolyzed, repeat sent. ECG done: no peaked T waves or QRS widening. Urgent: please call back within 15 minutes to confirm the plan. If the ECG changes, I'm giving calcium now and calling you.”

On the phone: SBAR

Situation	Who you are, who the patient is, why you are calling.
Background	The pertinent history and data, briefly.
Assessment	What you think is going on and how sick they are.
Recommendation	What you want done, and by when.

Etiquette

Use your hospital's secure messaging. No PHI in standard SMS.
One patient per message.
If it is urgent, call. Do not text an emergency; activate the rapid response or code team.
Acknowledge every page, even with “Seen, will call in 10.”
Close the loop: “Done. Repeat K 4.8.”
Overnight, save non-urgent questions for morning and batch them.

SBAR situation, background, assessment, recommendationMRN medical record numberK potassiumECG electrocardiogramQRS ventricular depolarization complex on the ECGPHI protected health informationSMS standard text message

Day One · 5 of 6

Know when to call your senior.

The ACGME requires every program to set guidelines for when residents must communicate with their supervisors, and every resident to know the limits of their authority (CPR 6.10). PGY-1s start under direct supervision (6.7.a). Learn your program's list. This is the floor.

Always call

Any rapid response or code.
New or worsening hypotension, hypoxia or rising oxygen needs.
An acute change in mental status.
Chest pain with ECG changes, or suspected ACS.
A new focal neurologic deficit.
Any transfer to a higher level of care.
A patient who wants to leave against medical advice.
An unexpected death, or a new code status or goals-of-care decision.
A medication error or safety event that reached the patient, or a procedure complication.
A nurse who is worried when you cannot explain why.
A procedure you are not yet approved to do on your own.
Any use of restraints.
A patient or family asking for the attending, or threatening a complaint.
Any time you are unsure. That is the trigger, not a weakness.

No good program penalizes an early call — The calls that hurt patients and careers are the ones not made. If you are deciding whether to call, call.

PGY-1 first postgraduate year (intern)ACS acute coronary syndrome

Day One · 6 of 6

Know the hours that protect you.

ACGME limits (Common Program Requirements, Residency, effective July 1, 2026)

Weekly maximum	80 hours, averaged over 4 weeks. Includes in-house work, clinical work done from home, and all moonlighting (6.20).
Shift length	24 hours of continuous scheduled clinical work, plus up to 4 hours for transitions of care and education. No new patients in those 4 hours (6.22).
Between shifts	Should have 8 hours off (6.21).
After 24-hour call	At least 14 hours free of clinical work and education (6.21.a).
Days off	At least 1 day in 7 free of clinical work and required education, averaged over 4 weeks. No at-home call on those days (6.21.b).
In-house call	No more often than every third night, averaged over 4 weeks (6.27).
Night float	Must fit within the 80-hour and 1-in-7 rules; your specialty may set further limits (6.26).
Moonlighting	Not permitted for PGY-1s (6.25.b).
At-home call	Time spent on patient care counts toward the 80 hours (6.28).

Work from home counts: EHR work and patient calls go toward the 80. Reading and studying do not. An interim revision on February 9, 2026 suspended enforcement of a few items, including rotation-specific exceptions up to 88 hours (6.24), but not the limits above. A proposed major rewrite of the Common Program Requirements was posted for comment on September 8, 2026 (proposal; comments due October 22, 2026; proposed effective date July 1, 2028). It renumbers section 6. The limits on this page are the ones in force now. Your Review Committee may add specialty rules.

Log the real hours — Under-reporting hides the problem from the only people who can fix the schedule.

EHR electronic health record

Educational reference only — not medical advice. Verify against local protocol.

Sources

Verify against current guidelines and local protocol before acting.

Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014;371(19):1803-12. doi:10.1056/NEJMsa1405556.
Starmer AJ, Spector ND, Srivastava R, et al. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics 2012;129(2):201-4. doi:10.1542/peds.2011-2966.
Institute for Healthcare Improvement. SBAR Tool: Situation-Background-Assessment-Recommendation. ihi.org.
Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency), FAQs incorporated July 1, 2026; effective July 1, 2026. Sections 6.7 (supervision), 6.10 (communication with supervising faculty), 6.19 (transitions of care), 6.20–6.28 (clinical and educational work hours).
The Joint Commission. National Performance Goals, Hospital Program, effective January 2026. NPG.01.01.01 (at least two patient identifiers).
Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency), proposed major revision posted for review and comment September 8, 2026 (comments due October 22, 2026; proposed effective date July 1, 2028). https://www.acgme.org/globalassets/pfassets/reviewandcomment/2026/cprresidency_rc_09082026.pdf
Workflow times and escalation lists here are practical defaults. Your program's supervision policy and specialty requirements take precedence.