patientflow

Patient Flow Chart, or How to Keep Your Attending Happy on Rounds!

Get patient's chart - if patient is having a procedure done the chart will probably not be in it's proper place (then again the chart will probably not be in its proper place anyway!).
Look at the previous day's progress notes first. This is especially important if your patient is labile. Who knows, your patient may have crashed the previous evening and had to be coded. It's always nice to know the status of your patient just in case the attending asks how things are going with Mrs. Smiley. It is so very embarrasing to say the patient is fine only to have the nurse accompanying you on rounds comment about a problem clearly documented in the chart!
Look at the previous day's orders and scut. If a CXR was ordered then you should probably track down the results, no? If a report has not been produced then consider getting the X-rays up to the floor for viewing. Most attending I know will want to see X-rays for themselves. I remember a time when a radiologist completely missed a subdural hematoma in a child and noted no abnormal finding in the report. When the attending took a look at the X-ray on rounds and saw the hematoma I thought the building was going to explode.
How about labs - it would be really nice to have the results of previously ordered labs in hand so you can interpret them. Don't be afraid to ask nursing staff where the results of a previously ordered lab are if they are not in the chart. In some hospitals lab reports will show up on a computer terminal before a paper copy is issued. Get yourself a login to be able to retrieve these on your own. Wouldn't it be nice to know whether your patient is hyponatremic, etc., etc? When you are looking at BMPs, CBCs, etc. don't forget things like sputum CX&S. Don't be caught with your pants down when the attending says "Mrs. Badblood is septic, what organism does her culture show?" Duh, gee Dr. X, I didn't look at the lab report (which had been in the cart since yesterday evening). You'll do this only once.
If this patient is a new admit yesterday and you notice in the H&P that they recently had a cardiac echo at another hospital then you will be THE MAN (figuratively speaking) if you call over to that other hospital and get a report of that cardiac echo faxed over right away. At least you can tell the attending that - "Dr. X, the other hospital has been called and asked to fax over a copy of MR. Jones' cardiac echo."
Look at things like BX reports. It is really bad form to give a patient a swish and swallow for a hoarse throat when the patient had a BX yesterday that clearly showed metaplasia, or possibly frank carcinoma.
EKGs, these are really important if a patient presents with chest pain. Check this out.
For heaven's sake, check out the patient's current meds. Is the patient still on furosemide IV? If not, then you are not going to look good at all if you recommend DCing the patient's furosemide when it has already been done!
Check out the vitals. It is nice to go into the patient's room and ask - "Hey, what's up with your blood pressure today?" You certainly can't do that unless you look at vitals. Oh, BTW, if the patient's BP is up YOU should recheck it and make a note in your progress notes to that effect. You don't need to do this, if it has been up for a week, only for an unexplained spike. Take a quick glance at the graphic of the temp. Note whether there are any upward trends. Downward trends from a febrile level will, of course, indicate recovery from an infection.
Check Is and Os. This is very, very important post op and in people with CHF and prone to pulmonary edema. If your patient's kidneys are not functioning you have got to do something. How about if the input is much greater than output? Better be checking for pulmonary edema when you go visit the patient and you need to think about turning down the IV or giving some Lasix depending on the clinical situation.
Check the patient's weight today compared to yesterday. If the patient's weight is down today but the Is are greater than Os then you'd better be questioning nursing about their accounting. Oh, yes, you can do this. You are the patient's advocate on the care team and one of the things that must be done, especially in the unit is accurate Is and Os. The patient's current weight and trend is a cross check on Is and Os.
For your own sake know the patient's current: BP, and blood glucose level (this should be FSBS done several times a day if the patient has DM) and drug allergies.
All this is called the chart review. It should give you a current picture of the patient's status before you go visit them.
Now, you can go visit the patient. Ask them how they feel compared to yesterday, etc. Check them over and don't skimp. Heaven help you if you didn't listen to that patient's lungs and all of a sudden there are crackles indicating a possible pulmonary infiltrate or you didn't listen to their heart and they have developed a pericardial friction rub. Incidently, when you are checking a patient for edema, especially an older patient in a nursing home consider what that patient has been doing most of the time - probably lying in bed. Therefore, you should check for pitting edema in the dependent portions of the body like the sacral area.
When you get back to the chart you can write your note, SOAP, of course. When you write your notes be thinking about your assessment and your treatment plan. These need to be verbose, especially the treatment plan. This needs to reflect you thought process and can include prospective treatment. Consider the following example entry under Plan.

Decrease prednisone to 25 mg - Mr. Jones' pulmonary function is clinically improved today. O2 sat is > 96% on RA and there are no active infiltrates on CXR. I plan to decrease Mr. Jones' prednisone to 25 mg starting today with the goal of weaning completely with a conservative taper. We will keep an eye on his adrenal function while this is being done. Ultimately I would like to begin Mr. Jones on a corticosteroid inhaler as a long term treatment for his asthma.

You can see that the previous entry is not just what you are going to do, but reflects your thought process regarding the ultimate long term goal for this patient.

After that you can write your orders. If you write an order for asap (never STAT unless it is truly necessary!) ABGs, labs, etc., don't forget to leave a comment about who should be called with results. The only STAT orders you should give are probably during a trauma in the ER or during a code.

Something you should always have in mind when you are managing a patient is - what is your end point? What I'm impying is this. Many times you will be dealing with a patient who has CHF or some other terminal process. Your end point or goal is to get your patient stable enough to leave the hospital. Many times you will not cure a patient but you certainly can get them out of the hospital to home, rehab, hospice, etc. Don't get caught up in thinking that every point of you problem list hast to be fixed in the hospital and that is the take home point.

By all means buy and use those cute little book's like Maxwell's, the "Sanford Guide to Antimicrobial Therapy", the Tarascon Pharmacopia, etc. They are great souces of information and no one will fault you for consulting them.

Keeping the above thoughts in mind will help you to have a successful hospital rotation and to help you instill a system approach to patient care in the hospital.