Author: TC Chen, MD | Editorial information | Discussion

On an inpatient service, a resident or medical student is expected to check the patient chart and visit the patient daily in the morning before the attending rounds.

This article is divided into three (3) sections, 1. chart review, 2. bedside visit, and 3. scenarios requiring interruption.

• BiPAP = bilevel positive airway pressure
• BMP = basic metabolic panel
• CBC = complete blood count
• CMP = comprehensive metabolic panel
• CPAP = continuous positive airway pressure
• LFT = liver function test

There are different ways you can review the chart, come up with a routine for yourself and stick to it. Depending on your personal preference and the electronic health record (EHR) system of your hospital, the following order may have to be adjusted or adapted.

• Look for new overnight notes for acute events.
• Review previous consult notes including specialists, therapies, and case management/social work.

• Look for the latest value as well as the trend overnight, in the past 24 hours, and since admission.

• Look for total intake and output. Note that it may not be recorded accurately so always verify at bedside.
• Also note the number of bowel movements (BM) if available, but again, verify.
• If patient has drains, note those values specifically. Otherwise report past 24-hour I/O, net I/O, and since admission.

• Note any medication that was started or given overnight.
• Note any fluid and drips.
• Review current medications.
• Also note any medication that has been held.

• Morning labs: CBC, BMP, LFT, and/or CMP.
• Follow up old labs: Cultures, send-out labs.

• XR chest: Review and compare to previous films (both on this admission and previous admissions/outpatient visits).
  • ICU: Note the distance between the tip of endotracheal tube and carina. Note all lines and tubes.
• XR abdomen or acute abdominal series
• CT head
• CT chest
• CTA chest
• CT abdomen/pelvis
• US abdomen
• US renal/bladder

• Electrocardiography (ECG, EKG)
• Echocardiography (Echo)
• Cardiac stress test

• Electroencephalography
• Endoscopy

• Go ahead and start a progress note for today, this allows you to review the current assessment and plans (A&P), update A&P as needed, and organize your thought before rounds.

• Review the drips hanging on the pole and the rate and dosing.

• Review the air flow of nasal canola (NC), CPAP, BiPAP, or mechanical ventilator (MV).
• If on NC, verify flow rate
• If on CPAP, BiPAP, or MV, document the settings

• If you are on the code team or you are required to respond to a code, as long as your patients are stable, you should respond to the code instead.

• If you noticed your patient is acutely deteriorating on chart (e.g. unstable vital signs, critical labs) or at bedside (e.g. unresponsive, acute chest pain with shortness of breath), immediately go check on the patient and notify the senior resident or attending physician.
• If patient has respiratory cession or loss of pulse, call a code first before notifying the senior resident and attending physician.
• Do not ever leave an unstable patient alone, call the nurse and notify the attending and stay until help has arrived.