Conducting Daily Rounds

Documents to Request

• Overnight nursing assessment and vital sign trends
• MAR (Medication Administration Record) with adherence notes
• Intake and output records from prior 24 hours
• New lab and imaging results since last round
• Consultant notes entered since last attending assessment
• Case management or social work updates
• Physical therapy / occupational therapy progress notes
• Patient or family communication log

Step 1: Pre-Rounding Data Synthesis (Before Bedside)

Complete the following data review for each patient before entering the room:

Vital Sign Trend Review

• Plot 24-hour trend for HR, BP, RR, O2 sat, temperature
• Calculate NEWS2 (National Early Warning Score) if not auto-populated
• Flag any vital sign that triggered a notification parameter overnight

Laboratory Review

Medication Review

• Verify all scheduled medications were administered (check MAR)
• Review PRN medication usage frequency (pain, nausea, sleep, anxiety)
• Check for new drug interactions with any medications added by consultants

Step 2: Bedside Assessment

At each patient's bedside, follow this structured approach:

1. Patient interview: Ask about overnight symptoms, pain level (0-10), sleep quality, appetite, mobility, bowel function, and any new concerns
2. Focused physical exam: Lungs, heart, abdomen, extremities (edema), IV sites, surgical sites, skin integrity (pressure injury check)
3. Line and device check: Foley catheter (day count — remove if day >= 3 without indication), central lines (day count, dressing status), drains, O2 delivery device
4. Safety assessment: Verify patient can reach call bell, bed alarm is active if indicated, fall precautions in place

Step 3: Problem-Oriented Plan Update

Document each active problem with the following structure:

Problem #[N]: [Problem Name]
- Subjective: Patient reports [symptoms/changes]
- Objective: [Relevant vitals, labs, exam findings]
- Assessment: [Improving / Stable / Worsening] — [brief clinical reasoning]
- Plan: [Specific orders, changes, or continuation]
- Disposition impact: [Does this problem affect discharge readiness?]

Common problem categories for hospitalized patients:

• Primary admitting diagnosis and treatment response
• Active infections and antibiotic day count (document "Antibiotic Day X of Y")
• Pain management with functional goals
• VTE prophylaxis (reassess daily)
• Glycemic management
• Fluid and electrolyte management
• Mobility and functional status
• Discharge planning and barriers

Step 4: Disposition Planning (Every Round)

Address discharge trajectory at every daily round:

• Estimated discharge date: State explicitly and update daily
• Discharge criteria checklist: What specific milestones must be met?
  • Afebrile >= 24 hours
  • Tolerating oral intake
  • Pain controlled on oral medications
  • Ambulating at baseline or with safe assistance plan
  • Pending results that would change management — identified and tracked
• Barriers to discharge: Document actively (insurance authorization, SNF bed availability, home safety evaluation, medication access, caregiver training)
• Case management notification: If LOS exceeds geometric mean for DRG, escalate

Step 5: Documentation and Communication

Ensure the rounding note addresses:

1. Time of service: Document start time for billing compliance (CMS time-based E/M)
2. Medical decision-making complexity: Clearly document data reviewed, diagnoses considered, and risk of complications
3. Patient understanding: Note if discharge plan was discussed with patient/family
4. Contingency plan: "If [X] occurs, then [Y]" — document clinical decision trees for nursing
5. Attestation: Attending must attest to any resident/APP-generated notes per CMS Teaching Physician rules

Checkpoint B: Post-Draft Alignment (Mandatory)

After completing rounding documentation for each patient:

1. Has every active problem been addressed with an updated plan?
2. Are all overnight events acknowledged in the note?
3. Has the discharge trajectory been updated with an estimated date?
4. Have pending results been listed with expected follow-up actions?
5. Is the note sufficient to justify continued inpatient stay to utilization review?

Quality Audit

• Every active problem has a documented assessment and updated plan
• Overnight events are acknowledged (even if "uneventful overnight" is stated)
• Vital sign trends are referenced, not just spot values
• All pending labs, imaging, and consults are listed with follow-up timeline
• Medication changes include rationale
• VTE prophylaxis is reassessed and documented
• Foley catheter and central line necessity are reassessed daily
• Discharge criteria and estimated discharge date are documented
• Patient and family communication is noted
• Code status is confirmed as current
• Functional status and mobility progress are documented
• Note meets E/M documentation requirements for the billed level of service
• Consultant recommendations are acknowledged with agree/disagree/modify notation

Guidelines

• Round in order of clinical acuity — sickest patients first, not by room number
• Never document "no overnight events" without verifying the nursing flowsheet and MAR
• Include antibiotic day counts in every infectious disease problem entry (e.g., "Vancomycin Day 3 of 14")
• Address device necessity daily — Foley catheters, central lines, and restraints require ongoing justification
• Document clinical reasoning, not just orders — "Switching to PO antibiotics because afebrile 48h, WBC normalizing, tolerating PO" is defensible; "D/C IV abx, start PO" is not
• Use "If…then" contingency statements to reduce unnecessary overnight pages
• Escalate to senior clinician when clinical trajectory is worsening despite current management plan
• Complete rounding documentation the same day — retrospective notes reduce accuracy and raise compliance risk