Morning Rounds Presentation
[Mr/Mrs/Ms] [last name] is a [age] year-old [female/male] who is post-op day [POD #] from [surgery] for [indication for surgery] Overnight, [he/she] [pertinent overnight events (fever, pain, etc)]. This morning [subjective exam: pain, fever, chills, nausea, vomiting, flatus, bowel movements, etc] [Her/his] vitals are [Tmax, Tcurrent, HR, BP, RR, O2 %, oxygen delivery] (do not need to say prefix, just give numbers) [Her/his] 24-hour ins/outs are [24hr I/O], with a urine output [most recent 8hr shift, previous 8hr shift, 8hr shift before that] per shift, and [any other tubes/drains that patient has - NG tube, JP drain, etc], [blood products if applicable - packed RBC, cryo, FFP, platelets] On exam, [patient] is [general exam - doing well, in no acute distress], Heart is [cardiac findings], Lungs are [pulmonary findings], abdominal exam reveals [abdominal findings]. Incisions/dressing is [findings - clean, dry, and intact]. Ostomy is [color, patency, protuberant or not, productive or not]. Vascular exam reveals [vascular findings, if pertinent]. [Any other pertinent exam findings] [Labs drawn - CMP, CBC w/ differential, etc] for [indication] shows [lab findings]. [Imaging study performed] done for [indication] shows [findings]. (only necessary to report if these are new labs or imaging studies) In summary, [patient] is [age] year-old [f/m] post-op day [POD #] from [surgery] for [indication for surgery] who is [general assessment, ie improving, stable, developing shock, septic, etc.] Plan for today is (pertinent info only): • Neuro/psych/pain • Respiratory (also include incentive spirometry, pulmonary toilet) • Cardiac • GI • GU/renal • Heme (include DVT prophylaxis) • Infectious disease • Endocrine • MSK/activity • Other pertinent systems (derm, rheum, etc.) • Dispo (rehab, home, transfer to ICU, keep on floor, etc.)
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