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Rounds are meetings of all members of the service for discussing the care of the patient. Rounds occur daily and are of three kinds.
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Also known as “work rounds,” morning rounds take place anywhere from 6:00 to 9:00 A.M. on most services and are attended by residents, interns, and students and in some hospitals and services, the attending physician. Morning rounds are the time for discussing what happened to the patient during the night, the progress of the patient’s evaluation or therapy or both, the laboratory and radiologic tests to be ordered for the patient, and, last but not least, talking with and evaluating the patient. Know about your patient’s most recent laboratory reports and progress; this is a chance for you to look good.
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Ideally, differences of opinion and glaring omissions in patient care are politely discussed and resolved at morning rounds. Writing new orders, filling out consultation forms, and making telephone calls related to the patient’s care are best done right after morning rounds. Discharge planning is an essential part of all morning rounds.
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Attending rounds vary greatly depending on the service and on the nature of the attending physician. The same people who gathered for morning rounds are at attending rounds, as is the attending. At this meeting, patients are often seen again (especially on the surgical services); significant new laboratory, radiographic images, and physical findings are described (often by the student caring for the patient); and new patients are formally presented to the attending (often by the medical student).
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The most important priority for the student on attending rounds is to know the patient. Be prepared to concisely tell the attending what has happened to the patient. Also, be ready to give a brief presentation of the patient’s illness, especially if it is unusual. The attending will probably not be interested in minor details that do not affect therapeutic decisions. In addition, the attending will probably not wish to hear a litany of normal laboratory values, only the pertinent ones, such as “Mrs. Pavona’s platelets are still 350,000/mL in spite of her bone marrow disease.” You do not have to tell everything you know on rounds, but you must be prepared to do so. You might be asked! (The essential components of the patient presentation can be found in Chapter 8, “Patient Presentations and Safe Handovers”.)
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Disputes among house staff and students are usually bad form on attending rounds. For this reason, the unwritten rule is that any differences of opinion not previously discussed should not be raised initially in the presence of the attending.
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Check-out or Evening Rounds
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Formal evening rounds on which the patients are seen by the entire team a second time are typically done only on surgical and pediatric services. Other services, such as medicine, often have check-out with the resident on call that evening (sometimes called “card rounds” and these meetings must be face-toface and follow an institutional protocol to help assure patient safety through efficient handovers. This is also reviewed in Chapter 8 “Patient Presentations and Safe Handovers”). Expect to convene for check-out rounds between 3:00 and 7:00 P.M. on most days.
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All new data are presented by the person who collected the test results (often the student). Orders are again written, laboratory tests desired for early the next day are requested, and those on call, compile a “scut list” of work to be done that night and a list of patients who need close attention. To comply with the ACGME directive regarding an 80-hour work week, many services have adopted “night-float” coverage systems. The interns and residents caring for your patients overnight will meet with the team at evening sign-out rounds. These cross-coverage strategies call for clear, concise communication essential during handovers.