The Efficient Rounder: Response to DB Medrants

At Medrants last week, Dr. DB raised several questions doctors ask themselves while rounding on patients:

1. Are we certain of the diagnoses - or do we need more diagnostic information?
2. If we are treating, is the treatment working?
3. What are our goals, or where are we going?
4. What are the patient’s goals and are we meeting them?
5. Does the patient understand the diagnosis, or the diagnostic workup?

I agree with the approach suggested by these questions, but I approach the process somewhat differently. These are the questions I used to organize my days on hospital rounds:

1. What is my game plan? Which patients can be discharged today? Are there any who sound sick or who need specialty consultation? These questions help determine the order in which I see patients.
2. For each patient, what is the working diagnosis justifying their admission? Are all the diagnostic studies completed? Do they support the working diagnosis or are further studies needed? Have the initial treatment modalities produced any improvement?
3. For each patient, what are the criteria for discharge? How close is the patient to meeting these criteria?
4. Does the patient understand her diagnosis and what the discharge criteria are? Do they have any concerns or goals for this hospitalization? Are their goals realistic? Are there any family members whose opinions you should solicit?

The efficient rounder asks these questions every day, and knows the majority of these questions can be answered by regularly reviewing the following sources:

Hospital census

Sign-out from day before

Lab/XRay reports

Nurses' notes

Discharge planner's notes

Physical/speech/occupational therapy notes

Patient's old chart

Of course, the ultimate answer to these questions can only be obtained by evaluating the patient in person. Getting the information you need from the patient is greatly aided by having reviewed all of the information discussed above.

My hospital still uses paper-based charting and requisitions, which is a barrier to efficiency. If we had electronically-entered orders, I could go from room to room without returning to the charting area, but as it is, I am limited to seeing 3-4 patients before sitting down with their charts to write progress notes and orders.

Probably the most important element of rounding is making up the game plan at the beginning of the day. Knowing who the patients are, where they are located, and in what order you can see them helps balance priorities for the remainder of the day.

I'm sure other doctors who provide hospital services approach rounds differently than I do, and I wouldn't mind a few friendly tips on how to improve!