Presenting on Rounds

Now that you've gathered all your information from pre-rounds, now is the time to get everyone on the same page and to convey any new information since rounds yesterday. While every attending will likely have their own preferences, by making sure that you consistently have the same information you’ll know that you’re hitting all the relevant points.

INTERVAL EVENTS:

E.g. procedures, consult recommendations, new medications started since last discussed
Overnight events

SUBJECTIVE: Patient’s self-reported complaints or symptoms. You are just reporting here, avoid interpretation

OBJECTIVE:

Vitals - list 24 hour ranges and most recent set if significantly different - try to avoid using the word “stable”
Physical Exam - list pertinent positives and negatives. Avoid using the word “normal”
Labs - report pertinent labs with trends (e.g. if trending sodium or WBC count, report the trend over the past few days). No other commentary – you are reporting objective data here, not interpreting.
New imaging
New micro data or path

ASSESSMENT: Who is this, what do they have, and what are we doing for them?

Components:

One-liner
- Age/gender
- Relevant PMH
- Presenting symptoms + timeframe and relevant context
- Objective findings identified during hospitalization
- Diagnosis or different diagnosis
Current treatment
Clinical status: patient is improving/worsening/unchanged
Example
- Age/gender with relevant PMH who presents with presenting symptoms + timeframe and relevant context, found to have objective findings identified during hospitalization, concerning for diagnosis. Currently treating with treatment. Patient is improving/worsening/unchanged.

PLAN: done by problem, in order from most pressing/urgent/active to least, unless in ICU where you go by organ system.