Essential Elements of Patient Review for Rounds
Introduction to Patient Review
- The American College of Physicians recommends mentally preparing before entering any patient room by reviewing the medical chart for documentation of previous discussions, anticipating patient emotional responses, and organizing the presentation framework 1, 2
Patient Assessment
- The American Diabetes Association suggests reviewing the patient's current treatment regimen, including all medications, adherence patterns, barriers to adherence, and previous treatment responses with documented health metrics 5, 6
- The American Heart Association recommends assessing comorbidity, including the number and severity of conditions, organ-specific function, and triggers for intensified monitoring 7, 4
- The National Comprehensive Cancer Network advises reviewing recent clinical events, such as hospital admissions, ED visits, ICU stays, functional status decline, and disease progression 1, 7
Patient Communication
- The American College of Cardiology recommends asking patients what they understand about their current medical situation before providing any new information 1, 9
- The Institute for Healthcare Improvement suggests providing information in small amounts using language appropriate to the patient's health literacy level, checking understanding frequently 1, 9
Safety Checks
- The Society of Hospital Medicine advises systematically verifying critical safety checks, including medication reconciliation, code status documentation, and VTE prophylaxis 4, 8
End-of-Life Care
- The American Society of Clinical Oncology recommends initiating advance care planning conversations within one month of terminal diagnosis and reassessing at sentinel events, such as cancer progression or functional status decline 1, 9
Documentation
- The Joint Commission suggests documenting the patient's understanding of their condition, goals of care discussions, advance directive status, and medication changes with rationale 1, 6, 2