DIP Episode 354 - Residency Skills: How to Pre-round Efficiently

Okay, welcome everyone. My name is Divine. This is episode 354 of the Divine Intervention Podcasts. And in today's podcast we're going to be talking about a residency skill. And I guess this is also a medical student skill how to pre-road. This should be a short and sweet podcast but it should be a very high value podcast especially for just clinical practice. And as I do just as a reminder if you're going to be taking the USMLS step 2 CK or step 3 exams within the month of December or the month of January, I strongly encourage you to attend the two courses I have actually next week. On the 6th of December which is next week Monday. I have an MBA Me testing and strategies course. It goes from 2 to 4 30 p.m. mountain time which is 4 to 6 30 p.m. Easter. And in that course we're going to be discussing many different MBA Me testing and strategies. Again I've seen many people where there are even Q bank percentages go up a lot after the attend the course. And even the MBA Me practice exams go up a lot. I get these very wonderful emails pretty much every Wednesday of how people have done really well on the exams. And then from the 7th to the 10th of December I have the 24 hour MBA Me review course. We're going to be reviewing Peds, Surgery, Internal Medicine, OBE Guy, Insight Neuro, Biostatistics, Ethics, Multisystem Processes, and Disorders. We're going to review a lot of very high-ill things. Over 24 hour period it's going to be from 10 a.m. to 4 p.m.

Mountain Standard Time from Tuesday the 7th to Friday the 10th of December. That's essentially from noon to 6 p.m. Easter and time. Again I've had many people take these courses. Don't really really well on the exams. So if you want a very good clutch, integrative review ahead of you exam and you're taking your Step 2, Step 3 exam or complex level 2 or 3 exams. In December we're generally, you should take the course. I'm pretty certain at this point, you know, by any means, on for sincere circumstances that my next course is not going to be until February. So let's get right into it. So pre-rounding. So pre-rounding, many met students are afraid of the stuff. Many residents are bogged down by this stuff but it's an essential part of clinical practice. That is just the truth. And again the thing is pre-rounding, even in the ICU, because you know the ICU, ICU rotations tend to be quite intense for many people. Shouldn't be the end of the world. You know, you shouldn't be the worst thing in the world. Pre-rounding is something that you should do with joy. It's something that you should be able to do pretty quickly. Even if you have a large number of patients, at least I will say from personal experience, there are times in my life where I've had like maybe like eight patients that I have to pre-round on and see and write notes on. Just again, because of the technicalities of clinical practice, sometimes things just get busy and everyone needs to pitch it.

But I will say for a met student that's highly unlikely to be the case. For most met students, the maximum number of patients they'll probably put you with is probably 304. And you know, as a resident, especially as an intern, I will say you know probably five is what you're looking at in terms of if you're getting a ton of patients. I will say a decent number of patients getting a ton of patients is like getting either nine. So how do you pre-round? Let's just get right into it. So the very first thing you do when you pre-round is to get to work on time. This is a problem for many people. You see them become when sign out like oh two minutes before sign out from you over my team. That's usually not a smart or a pretty idea. Again, I know yes, it's going to rob you of some sleep. But you're going to get that time back on the back end. So just show up on time. For me, during my transitional year, I had a practice of showing up to work many times about 15 to 30 minutes before sign out. 15 to 30 minutes before sign out. Again, you will see exactly why this is very helpful as we as we go along. Right? But just show up on time. If you show up on time, even if you're going to meet chaos at work, you are better able to control that chaos because you just showed up to the chaos before everyone else. That is just the truth. So some people may say, oh, this has been a gunner or whatever. It's not. It's just common sense and wisdom. And you'll see why as we go along.

But even if it's just 15 minutes ahead, it just really, really helps. Just show up on time. The thing is if you show up on time, you'll not be caught by many surprises. So now you get to work before sign out. Okay, so what's the second thing that you do? The second thing that you do is that you do a chart biopsy, right? So what do I mean by a chart biopsy? So if you know the patients, you're going to be attending to during the day, you need to look at three things in the chart. One, you need to look at what the nurse has done overnight, right? What fluids did she give? Did she take any vitals overnight? Did she write any little notes? You know, nurses have their little notes, they write overnight. Check those things out. Two, look at the notes from the previous day, right? So look at the notes from the nurses, look at the notes from the physicians, look at the consult notes. And to be honest with you, before you panic and say, Oh, wow, Devan, you're giving me so many notes to read. The thing I really want you to do is to look at the assessment and plan. That's really what you should be looking at. Look at the assessment and plan. If you look at the notes, you yourself wrote the previous day, right? Just look at the assessment and plan. That's going to be the highest yield section that will give you the biggest band for your buck. And then the third thing you look at, look at the vitals and the labs that happened overnight, they are just not aware of, right?

So things like urine output, things like the medications they're getting, I always like to check the mar in the EMR, right? Just check the medications that they're getting, check the urine output, check their vitals. And the thing you're trying to spot, you're looking for trends, right? So if you notice that the presence of the glubing is going up, that's good. If you notice that the presence of urine output is coming down, that's bad, right? So you just want to check out these trends, trends, trends. It's just very helpful. And the thing is, when you're doing this chart biopsy, the smart thing to do is literally be making a problem. Let's just be right to need down, right? Anything you find that is egregious. So anything you find that you're like, man, this thing is not good. Try to write it down. Try to write it down. If you write it down, then you're going to be saving yourself time because those are the things you're going to be focusing on, right? So that's what you do first. And then the next thing you do is you get sign out, right, from the overnight team. You get sign out from them, right? On your patients, right? Again, just many times if you've done step one well, then this sign out from the overnight team, you're really not going to get very much from it to be honest with you because you've just kind of done the legwork. Now the moment you're done getting sign out from the overnight team, the next thing you need to go to immediately is the overnight nurse.

So that's the next step. Go to the overnight nurse, right? And the thing is to be honest with you, it is good etiquette in healthcare to see the overnight nurse before the nursing sign out because it's kind of tacky. It's kind of mean to try to get sign out from a nurse when they've studied their own sign out, right? Because these people, they've worked overnight, they're trying to get home to their families. It just kind of seems like the right thing to do to just meet them beforehand. And I'm telling you, this overnight nurse is a good mind of information, right? So meet them, ask them, oh, I'm being respectful. Be respectful like because again, they've had to work overnight. You don't know the kind of nights they've had, right? Again, especially nurses in the ICU. So just be kind to them, smile for them, right? If you have a chocolate bar or something, hand to them, you know, just something to give them that good sugar surge in the morning, right? So just ask the overnight nurse, you know, how are things overnight? How are things overnight? Many times they will tell you all that you're going to get from the patient if you're walked into the room to see them. To be honest with you, almost exclusively never saw the patient before I saw the nurse. No, I was going to see the overnight nurse first before I saw the patient because again, believe it or not, the nurses are there. They're literally at the bedside. They know exactly what is going on with the patient, right?

So ask the overnight nurse, what happened overnight? Any changes overnight, anything we're concerned about. And then one question I always ask the overnight nurses, is there anything you would like me to do today for this patient that I have my own ideas, but I just want to hear you out. Is there anything you would like me to do today? Again, many times the thing is you cannot know the patient as intimately as the nurse that is taking care of safe patient, right? Many times they'll say, you know, I think it's a little dry. You may get any minute fluids this and that. If you do that, again, you're just building up your assessment and plan very rapidly. And then after you do that, thank the nurse, again, respect and respect for us and you know, being humble is always appreciated in health care. And then after that, go and see the patient. Go and see the patient. Just see the patient real quick, right? You don't just see how I missed her, whatever misses, whatever. How was your night? You know, say hello to them. Do a focused exam, right? Do a focused exam. And then after that, the next thing you do is you go into the electronic medical record and start writing your note, start writing your progress note. Your progress note should be an assessment and plan. Start with the assessment and plan first. Don't worry about the subjective, objective, all that whatever. Start with the assessment and plan. And where do you get your assessment and plan from?

Well, you get it from these things you've been collecting, right? So remember that chart biopsy? You did in the first early step where I was like, oh, the nurse is not from overnight, not from yesterday, vitals and labs that have happened overnight or whatever, right? Those are the problems, right? Just write down those things and then write down what you want to do for them, right? And to be honest with you, as you are writing these assessment and plans, one thing that is prudent or is wise, but this is probably more under the purview of a resident than a medical student is those things you are doing, if there are labs you want to get done, right? You're like, oh, this person is, this person's hemoglobin is like 6.5. Okay, I want to give one unit of blood. Just go ahead and start putting in those orders, right? But first write the assessment and plan. And then after that, you won't, again, this thing doesn't take that much time. Just putting those orders, putting those consults, right? Just do them there, like there and there, right? There and there, right? And then after you've done the assessment and plan, then go back and write the subjective. And again, I feel like many people are very verbose in the medical record, right? Just calm down, right? We're not trying to read a novel, we're not trying to read an essay from you. Just write the stuff that is short, sweet and to the point. Even in the ICU, short sweet and to the point.

Don't miss out on anything important, but I feel like one problem with many people is they have this thing of the use templates for stuff. And then they populate their notes for the patient, just a lot of crap that does not need to be there, right? So the stuff that is important, just put it in, right? Be high yield, be high yield, be high yield, right? The things that are the most important, right? Write the note, but don't sign the note yet. Just save it, just save it. And then after you do this, go for rounds, go for rounds, right? Go for rounds. The thing is during rounds, obviously, the whole team is going to see the patient. You're going to be taking advantage of the collective expertise of everybody on the team. So if they spot anything that has, oh, that needs to be done, that, oh, you didn't think about, you can just write it down and modify your assessment and plan, right? So you go on rounds, you go on rounds, and in fact, to be honest, we've used sometimes during rounds, I'm like putting in orders for people, right? So in fact, sometimes things go so well that if, because if you've done all these steps, I've told you to do well, believe it or not, there are some times where I actually sign my notes for a patient on rounds, right? On rounds, because most times if you go through this high fidelity process, I've just described, it's very hard for you to miss anything, literally, right?

So, right, just, you know, just on, we're going rounds, anything you want to see or whatever, you know, write it down, you don't modify your assessment and plan or whatever. But after that, then, after rounds, after rounds, this is very important. This is like a problem with many residents. Again, I'm not trying to call people out here, but it's just a very big problem in residency. After rounds, don't daily dali. What do I mean by daily dali? Daily dali means just wasting time. I feel like many times after rounds, you are like, woof, rounds are done, and then they go, they chill in the workroom, they watch TV, they chat with the other residents, they go to the hospital cafeteria to grab food and all those things. To be honest with you, one policy you should have is I am not going to have food, I'm not going to daily until I've completed all my notes. The thing is, you need to work with a sense of urgency if you want to be efficient as a medical student or as a resident, right? So, just have a no food, no daily dali policy until my notes are signed. Now, the thing is, after you write your notes, for each of the patients you have, have a very quick separate checklist. You know, just you're like, oh, this five or seven things that, and your checklist really should have two things. One, what are the things I'm trying to track today for these patients? Two, what are the things that need to get done for the patient that have not been done?

Write those things down in a separate checklist, right? In a separate checklist. As you get these things done, check them off your list. And to be honest with you, try to completely check list before no conference. That is usually a smart idea. Try to get your list checked out like complete, your checklist done before no conference. And then, just as a bonus, I'll just throw in the fact that many times, especially in the ICU, one smart idea is to do something I call hourly rounds. What do I mean by hourly rounds? I do not mean that, oh, wow, go to your patients and check them out every hour. No, you very likely don't have time for that. But to be honest with you, at least every hour, you should spend like two, between two to five minutes, and just going to the medical record real quick and check. Okay, these things that I wanted to get done have been done. How is this patient doing? How are things evolving? Right? If you need to call the nurse, call the nurse or pitch the nurse, right? Again, just if you do these hourly rounds, it's almost like you're like, almost like the NSA that is just overseeing your patients and you're not missing out on anything, you're catching every communication, right? You're just not going to get too many surprises if you follow this mantra. So I think I'm going to go ahead and stop here. But again, I'm really telling you, if you follow these rules, and the thing is, when you follow them, you're going to be slow at first.

I'm telling you the truth. You're going to be slow at first, right? I remember my first ICU, like my first few days in the ICU during my transitional year. I was really slow with my patients. Really, really slow. Once I developed an approach, I got really fast. You will give me five, six ICU patients, and I'll be done pre-rounding and writing the notes and everything for them in about maybe an hour or like an hour and a half tops on a slow or me, like on a day where I'm like, wow, really slow or I'm like being pressed for time. So I'll just encourage you, just follow these steps, right? Practice them a few days in a row. When you do that, you'll notice that these things will be common a lot easier. So thank you for listening to me today. Again, as I do at the end of every podcast, I draw for one or one tiering for many exams. Step one, step two, CK, step three, complex level one through three, pre-clinical medical exams, third year shelf exams. The only thing I don't offer tiering for is is OEMM. And then, again, I also offer the review courses for step two, CK and step three. Again, those review courses also apply to people taking complex level two and three. And then, I have a new website, Divine Intervention, Life Lessons.com. In fact, there is an Apple podcast for it. It's called The Divine Intervention Life Lessons Podcast. And again, right now, I believe I have about 49 or 40 episodes. I try to do like, you know, one to two episodes a week.

For the most part, it's usually two per week, usually on Fridays and Sundays, where I have a short podcast on a life lesson or something that is relevant to just, you know, common problem that's faced by humanity. And then, I have these podcasts, at least the most recent 150, on Apple podcasts, on Google podcasts, and on Spotify, right? If you want everything from episode one, all the way to this current episode, episode 354, then you have to go on the website, Divine Intervention Pot Casts.com. If you actually subscribe on that website, you need, I think, you need a Word Press account for that. You'll get an email notification whenever I make a new podcast. And then, I have a You Tube channel, Divine Intervention, USMLE Podcasts and Videos. That's where I post the videos that I make. I've actually posted some videos in recent times, and I'm going to be posting more. Again, I'm going to try to post quite frequently. So just subscribe, Divine Intervention, USMLE Podcasts and Videos, and you'll see my picture there. You just subscribe, and again, you, you, you, and you just hit that subscribe button, and you get a notification whenever I make, make a new post. And then, the one thing I guess I want to say, as a very quick, rapid life lesson today, is the importance of living your life on laws, being a principled person. The thing is, there are two things that can drive a human being in life. It can be your emotions, or it can be principles.

Many people, unfortunately, are driven by emotions. But the thing is, emotions are very, they change a lot, the vastly later from time to time, right? Like you see, some people, they are not feeling it in the morning, but then in the afternoon, they're in the zone, right? But the thing is, principles don't change, right? Principles, they're principles for reason, they are hard and fast, right? So, find good principles. There are many places you can find good principles in this life. You can find good principles from the Bible, you can find good principles good You Tube videos, you can find good principles from newspapers, just ask yourself, what is the right principle for this thing I'm doing? And then plug yourself into that principle, when you plug yourself into that principle, then success is inevitable. That is just the truth. But you see, many people, they live based on emotions, right? Because the thing is emotions are more about the here and now. Principles have thought about all the different circumstances that can happen, and are more long term in the approach, right? So, I'll encourage you to be a principled person. Don't be a person of pleasure. Be a person of principle. When you're a person of principle, then you are living life on the higher way. So, thank you for listening to the podcast. Until next time, have a wonderful day. God bless you. Thank you.

Arrive at work 15–30 minutes before sign out to gain control of the environment and avoid surprises.

To systematically review three areas: overnight nurse notes/vitals, previous day's A/P section, and overnight labs/vital trends.

The Assessment & Plan (A/P) section from the previous day, as it is the highest yield summary of care.

The overnight nurse, because they are at the bedside and provide real-time information that cannot be found in written notes.

Start with the Assessment & Plan (A/P) first, using the identified problems from your chart biopsy to guide the content.

Perform "hourly rounds" by spending 2–5 minutes checking the EMR for updates and pending tasks.

1) Overnight nurse notes/vitals; 2) Previous day's Assessment & Plan (A/P); 3) Overnight labs and vital trends.

Nurses are at the bedside and provide immediate, crucial information about subtle changes that written records might miss.

The problems ("things that are not good") identified during your chart biopsy.

Start with A/P $\rightarrow$ Write Subjective/Objective data to support the A/P $\rightarrow$ Finalize orders.

Wasting time after rounds (e.g., socializing, waiting for food) before completing all necessary documentation and notes.

Keep notes short, sweet, and highly focused on high-yield information; avoid verbose narratives or unnecessary template filler.

1) Overnight nurse notes/vitals; 2) Previous day's Assessment & Plan (A/P); 3) Overnight labs and vital trends.

Nurses are at the bedside and provide immediate, crucial information about subtle changes that written records might miss.

The problems ("things that are not good") identified during your chart biopsy.

Start with A/P $\rightarrow$ Write Subjective/Objective data to support the A/P $\rightarrow$ Finalize orders.

Wasting time after rounds (e.g., socializing, waiting for food) before completing all necessary documentation and notes.

Keep notes short, sweet, and highly focused on high-yield information; avoid verbose narratives or unnecessary template filler.