The Ritual of Pre-Rounding

View of North Miami Beach from Mt. Sinai Hospital

Every morning around the world, medical students and interns wake up early before the sun rises, and head over to the hospital to partake in a certain ritual of medical education: the ritual of pre-rounding.

So what is it? It’s when we go see the patients before the attending physician comes and do his/her normal rounds. By pre-rounding before the doctor rounds, we can gather information, check how the patient is doing, write a progress note for the doctor, and present our assessments to the attending before he/she sees the patient, and that way it helps the doctor save time and effort in doing all this. Pre-rounding is good because it helps us students get involved in the patients’ care, gives us some one-on-one time with the patients so we can practice rounding on them as future physicians, and helps the doctor out.

Different hospitals or attendings may differ on how they want you to pre-round, but here are the things that I do when I pre-round:

  1. On the floor here, they print out a list of all the patients on the floor that needs to be seen for that day. Since different patients are assigned to different doctors, I circle all the ones that are my attending’s patients. Sometimes there’s 3-4 patients that day, and other times there’s 9-10. Depending on how many other medical students you are working with, you may decide to split up the patients so that each student sees a few, helping each other out.
  2. I get the patient’s chart and read the progress notes from the previous days, to get a background information about the patient. If necessary, you can also talk to the nurse in charge of the patient to get updated about the patient.
  3. I get the lab results and vitals of each patient either from the computer or from a nurse (if it’s not entered into the computer yet). I then either print out the info or jot down the numbers or results. I check to make sure the lab values are ok and the patient is doing fine. If not, I note it down so that I can put it in the progress note and present it to the attending when he/she comes.
  4. I then go see the patient. I ask them questions to see how they are doing, then do a short physical exam.
  5. I go back to the patient’s chart, write down my findings on the progress note. A popular way to write a progress note is to write a “SOAP note.” SOAP stands for Subjective, Objective, Assessment, and Plan. In a SOAP note, you organize your progress note around 4 key component:
      1. SSubjective is what the patient says. It could be quotes, or it could be information that the patient tells you. You also write the symptoms the patient denies having here.  i.e. “Pt c/o mild lower abd pain but says otherwise ‘doing well’. Denies N/V/HA/CP/SOB…” etc.
      2. OObjective is what you find out about the patient, from physical examination, vitals, or lab values that you looked up about the patient. i.e. “NAD, HRRR, lungs clear, Abd soft/NT, no edema. Vitals: 97°-80-12-110/70. Labs: WBC 5.0, Hb 9.1….” etc.
      3. AAssessment is a brief statement summarizing the big picture of how the patient is doing. i.e. “28 yo G1P1 EDC 9/2/12 s/p ND day #2 doing well…” etc.
      4. PPlan is what you plan to do for this patient, like which medication you will prescribe, what the patient should do, what further test you want to order for the patient, or when the patient should follow up. i.e. ” continue post-partum care, repeat complete blood count in the morning, control pain with motrin…” etc.
  6. I then jot down a summary of the patients’ information and my findings on my own personal notebook (which I recommend carrying around with you at all times) so that I may have something to look back on when I present the patient to my attending physician.
  7. We keep doing this for the rest of the patients, and finish seeing all of them before the attending physician arrives on the floor. When the attending comes, we then do rounds again with him/her. Before we see each patient, I present my findings to the attending. After the doctor has an idea about the patient, we all go into the patient’s room together to see the patient.
  8. Afterwards, the doctor reads over what I wrote in the progress note, and edits it (if needed), then signs it… then we move onto the next patient.

Different attendings may prefer different formats for the SOAP note, or prefer you present cases in a particular way. Some doctors don’t care as much, as long as the information is organized and easy to read or understand. When in doubt, it’s always considerate to ask the doctor beforehand for their particular preferences.