What is the best approach to prepare for morning rounds in a clinical setting, considering patients of all demographics and medical histories?

How to Prepare for Morning Rounds

Before each patient encounter, clinicians must review the patient's complete medical information, establish 1-3 specific goals for the conversation, and anticipate both the patient's needs and their emotional responses. 1

Pre-Rounds Preparation (Before Arriving)

Review Patient Medical Information

• Examine the complete medical record including cardiovascular diagnoses, surgical procedures with ventricular function assessment, all comorbidities (peripheral arterial disease, cerebrovascular disease, pulmonary disease, kidney disease, diabetes mellitus, musculoskeletal and neuromuscular disorders, depression), and document severity assessment and impact on quality of life 2
• Review recent laboratory results, imaging studies, and microbiology findings to avoid information gaps during rounds, as microbiology findings (10%) and surgical procedures (6%) are the most commonly missing information 3
• Check medication lists for appropriate doses of critical medications (aspirin, clopidogrel, β-blockers, lipid-lowering agents, ACE inhibitors or angiotensin receptor blockers), evaluate risk-benefit of each drug, possible interactions and adverse effects, and adherence to treatment 2
• Review documentation from previous end-of-life discussions if applicable, as this should be checked before any new conversations 1

Establish Goals and Anticipate Needs

• Define 1-3 specific take-home messages you want to communicate during each patient encounter 1
• Anticipate emotional responses of patients and family members based on their clinical situation 1
• Anticipate questions that might be asked by patients, families, or team members 1
• Identify who should be present for the conversation, including family members who may need teleconference access if they cannot attend in person 1

Logistical Preparation

• Arrange appropriate location and time to give information and answer questions without interruptions 1
• Ensure organizational measures allow for undisturbed rounds so you can concentrate on patient inspection 1
• Have all necessary information to conduct an effective encounter, including recent hemogram and electrolytes if warranted 1

Structure of Morning Rounds

Initial Patient Approach

• Address the patient by saying "hello" at the start of each bedside discussion 3
• Introduce yourself and your role in the patient's care 1
• Sit down to foster trust and collaboration 1
• Make eye contact and maintain a calm demeanor throughout the encounter 1

Information Gathering and Presentation

• Use open-ended questions to explore the patient's understanding of their disease and encourage them to share what is important to them 1
• Collaboratively set an agenda after inquiring what the patient and family wish to address and explaining what you wish to address 1
• Present information systematically: case history, acute status (findings and strategy including function of main organ systems), infection status, and nursing problems 3
• Address specific organ systems in more than 60% of discussions: respiratory (including inspired O2 concentration and ventilation mode), neurological, cardiovascular (including blood pressure and pulse), as well as surgical and nursing problems 3

Physical Examination

• Examine patients at the bedside with the attending whenever possible, as fellows most value bedside discussions for building clinical skills (34%), though only 30% examine all patients with the attending 4
• Assess cardiopulmonary systems including pulse rate and regularity, blood pressure, auscultation of heart and lungs, palpation and inspection of lower extremities for edema and arterial pulses, post-cardiovascular procedure wound sites, orthopedic and neuromuscular status, and cognitive function 2

Communication During Rounds

• Engage in reflective listening and be friendly but not overly casual 1
• Use simple language tailored to the patient's educational level and provide information in small amounts, checking understanding frequently 1
• Include involved clinic or bedside nurses in discussions, as they often have valuable contributions and will be present when questions arise after you leave 1
• Minimize interruptions, as only 17% of interruptions during rounds are related to urgent decisions 3

Documentation and Follow-Up

During Rounds

• Document discussions in the medical record immediately, including important conversations about treatment options and end-of-life preferences 1
• Use standardized checklists during handovers and at regular intervals, as routine checks detect 50% of critical incidents 1

Post-Rounds Tasks

• Complete progress notes efficiently, though be aware that 46% of fellows complete notes after 5:00 pm and 36% of program directors after 8:00 pm 4
• Create a treatment plan that prioritizes goals and outlines intervention strategies for risk reduction 2
• Document specific referral information, symptom severity level, barriers to care, and follow-up timeline 2

Common Pitfalls to Avoid

• Avoid conducting rounds without examining patients at the bedside, as bedside discussion is most valued for clinical skill development 4
• Don't allow hierarchical structures to impede communication, as data from the airline industry shows this is not good for safety 1
• Prevent fatigue-related errors by ensuring work hours are not excessive, as fatigue impairs performance 1
• Minimize sleep disruption for patients by avoiding traditional 3:00-6:00 AM blood draws when possible, as these adversely impact patient care 5
• Address conflicts promptly through daily "reflection" circles with nursing and medical staff, as conflict is a significant risk factor for poor performance 1

Special Considerations for Family Involvement

• Offer parents or guardians of children the opportunity to participate in rounds, as 94% of patients view participation as positive and 66% report improved communication 1
• Give adult patients or surrogate decision makers the opportunity to participate in rounds whenever possible 1
• Allow patients and family members who participate to ask questions to clarify information discussed 1
• Inquire about family members unable to attend and consider offering teleconference for people important to the patient 1