Surgical Rotation: How to Review Patient Charts

You have 30 minutes before morning rounds - what is the most efficient way to chart check the patients for the day? Note that while this article can be applied to any rotation, it is specifically written emphasizing details relevant to a surgical patient.

Vitals

The first numbers I always check are the vitals overnight - generally, I am looking at temperature, heart rate, respiratory rate, and blood pressure. If there are abnormal values, I consider whether it was a singular event or if it represents a true change in the patient’s condition. Regarding oxygenation, I note whether patients are on room air, have supplemental oxygen, are intubated, etc. If they are on additional oxygen, note the flow and whether it has changed from the day prior.

Drains and Tubes

Are there drains and tubes? And if so, what has been the output? Be sure to compare numbers from the days prior.

Ins & Outs

Consider what their form of intake is. If by mouth (PO), what diet do they have - regular, soft, clear liquids, etc? Do they have a nasogastric (NG) tube? Are they on any IV fluids?

For the outs, are they urinating? Have they had any bowel movements? Is there a Foley?

Labs

Important labs to check for are complete blood counts (CBC) and basic metabolic panel (BMP), and I look to see if there are any abnormal values. Sometimes labs can still be pending, in which case I make a note to myself to check the results later in the day. Values I generally look for are white blood cells (WBC) and hemoglobin (Hg). For electrolytes, the rule of thumb I use is 2, 3, and 4 for Mg, Phos, and K. I also check creatinine and glucose in the same report.

Micro & Radiology

Next, I check for new results regarding culture growth or radiology reports. Especially for cultures, growths are followed for a few days. Thus, no growth after one day is not considered a “negative” result but is phrased as “no growth to date.” If a microbe is found, susceptibility to antibiotics will be performed, which can take additional days. Usually, teams will start an empiric antibiotic therapy and tailor the regimen once the results are finalized. Sometimes, the Infectious Disease team can recommend antibiotic therapy until cultures have been negative for X number of days. So be sure to track what day the cultures were initially collected.

Medications

Important medications are pain control, antibiotics (PO or IV), and prophylaxis for deep vein thrombosis (DVT). I check to see if there have been any changes from the previous day. Regarding antibiotics, it is always good to note when it was started and the expected end date.

Notes

If I have time, I also review notes by the overnight nurses to see if there were any acute events. You can talk to the nurses in person before rounds, but if you cannot find them or do not have time, this is a good way to ensure you do not miss any important events.

Extra

Lastly, I check for patient-specific to-dos. For example, if we placed a consult, I check to see if there has been a new note. What is the disposition plan for the patient, and what must be done to meet this goal? Depending on your role in the team, you can also see if dressings for any wounds are specified so that you can be prepared during rounds.

It may seem like a lot of information to digest early in the morning, but it gets easier with practice! I personally found that as I moved through the rotation, the chart review time got shorter, particularly as I got to know the patients better. Everyone develops their own flow that optimizes this process, and you can always ask a team member if they have any shortcuts that make navigating the online medical record easier.