Posted by: notdeaddinosaur | March 4, 2010

Always See the Patient First

There’s a very important rule to remember when rounding in the hospital. Personally, I would think that it’s self-evident, but apparently not, according to a recent trainee in my office, who told me the following story.

Rounding on patients in the hospital has several components. In addition to seeing and examining the patient, one generally peruses the results of lab tests and other new studies, collects the most recently measured vital signs, consults with the nursing staff about the patient’s status, and documents the encounter.

I well remember my student and resident days, when the major goal felt like collecting material for the progress note. After a patient had been in the hospital for some time, figuring out how to write something other than, “Continue present management” gets to be a real challenge.

It turns out that after perusing the current results of lab tests and other studies and getting the vital signs from the nurse, my new friend began writing the patient’s progress note. He spoke with the current nurse who confirmed the patient’s stable status, and duly noted same in his progress note-in-progress. Finally he went to see the patient…

Who was stone cold dead.

Suffice it to say, he had some re-writing to do.

Hence, the very important rule of rounding in the hospital: Always see the patient before writing the note.

Regarding today’s date: thanks for all the good wishes. DS is taking me out for sushi, which is celebration aplenty.


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