I’ve worked in very high-volume settings. In a prior job, I did moonlighting where I would round on thirty-something patients per day, sometimes with ten or more admissions in a single day. Efficiency mattered a lot there, because otherwise you simply could not get through the work. I don’t recommend that kind of volume, by the way.
Fortunately, academic medicine is more reasonable. I’m capped at twelve patients and have excellent social work assistance. What I want to focus on here are a few different rounding models I’ve tried, what’s worked for me, and a couple of simple frameworks I use regularly to stay systematic.
I’ve tried three rounding models.
The most common rounding model in my experience as a medical student and resident is where you show up in the morning, do a little pre-charting either that morning or the night before, then have a brief meeting where you get a nursing report. After that, you print your patient list and start seeing patients one by one. You might jot notes on your printout or try to keep everything in your head. Once you’ve seen everyone, you go back, put in consults, orders, and then spend the rest of the day writing notes and dealing with fires as they come up.
I still do this sometimes. The problem for me is that I get very burned out writing twelve or more notes in a row. I lose focus quickly, it feels painful, and it’s not how I do my best work.
The second model is seeing each patient one by one and finishing everything for that patient before moving on. That means seeing the patient, writing the note, putting in orders, and addressing whatever needs to be addressed right then. If the patient is calm enough, I’ll bring them into a room with a computer and type while we talk. If not, I’ll do it immediately afterward.
This has actually become my preferred way of rounding. It does mean that I may not finish seeing patients until early afternoon, whereas with the first model you can often finish seeing everyone before lunch. But once I’m done, I’m done. Notes are in. Orders are in. There’s no looming pile of documentation waiting for me. Psychologically, that makes a big difference.
There’s also a mixed model, which is probably my second favorite. In this approach, you do deeper pre-charting in the morning. You prep most of each note ahead of time, often everything except the subjective section. Based on the nursing report and the patient’s trajectory, you usually already know what you’re going to do with medications and orders, so you can often update those in advance as well. Then you round on all your patients. You still have notes to finish afterward, but much less work per note.
My least favorite model is seeing everyone in the morning and then doing all the notes afterward. On one hand, it feels good to say you’ve seen all your patients. In a worst-case scenario, you can even finish notes at home. But for me, having a big block of notes waiting is draining and gets me burned out.
A simple daily checklist: FLOP SEND
Regardless of the rounding model, I try to be very systematic in how I approach each patient. I use a simple mnemonic I came up with called FLOP SEND.
F is for flow sheets. In my EMR, that’s where vitals are recorded. I always check the most recent vitals and trends. Is my patient on clozapine becoming tachycardic? Is blood pressure creeping up?
L is for labs. Are there any new results I need to act on?
O is for orders. In my EMR, some orders are required to have an expiration date, so sometimes orders expire unintentionally. Consults fall off. Labs are due. I check that everything is current and put in new orders as needed.
P is for problem list. I write problem-based notes, and it’s easy to forget things, especially chronic issues like hypertension, diabetes, and hypothyroidism. I make sure they’re all accounted for in my notes.
S is for sleep. I think of sleep as a psychiatric vital sign. I always check how many hours the patient slept overnight. Minimal sleep is almost always something I need to address. Or sometimes hypersomnia is the problem.
E is for events. Were there restraints, seclusion, emergency PRNs, or other significant overnight issues?
N is for note. Just a checklist item to do my documentation.
D is for discharge planning. I try to be thinking about discharge from day one. Where are they going? What aftercare will they have? How are we thinking about relapse prevention?
They’re not necessarily in the perfect order, but as a checklist, FLOP SEND keeps me from missing the important things.
A differential diagnosis framework: MINDSPACE
The last thing I want to share is a mnemonic I use for differential diagnosis on the inpatient unit when seeing new admissions.
It’s called MINDSPACE.
When someone is admitted to inpatient psych for “erratic behavior” (a common presentation for me), there are a lot of possible explanations. MINDSPACE helps me stay systematic.
M is for mania or manic-depression, what we now call bipolar spectrum disorders.
I is for intoxicant, meaning substance-induced conditions, including intoxication and withdrawal.
N is for neurodegenerative or acquired brain disease, such as dementia or traumatic brain injury.
D is for (neuro)developmental conditions, like autism.
S is for schizophrenia spectrum disorders.
P is for personality disorders.
A is for adjustment disorders, where something bad has happened and the patient is having a severe but understandable reaction.
C is for catatonia. Catatonia is always secondary to something else, but it’s common enough on inpatient units that I want it explicitly on my differential so I don’t miss it.
E is for encephalopathy. This is where orientation, memory, or attention are impaired, and where I need make sure the patient really was “medically cleared.”
This framework isn’t perfect. No framework is. More than one thing can be going on at once. But as a quick mnemonic to avoid diagnostic premature closure, it helps.
That’s it. I hope some of this is helpful to someone out there.
