CHPPC Module 23, Section 1: What Rounds Look Like
MODULE 23: CLINICAL PHARMACY ON THE FLOORS: MASTERING PATIENT CARE ROUNDS

Section 23.1: What Rounds Look Like: The Formats, The Players, and The Unwritten Rules

Stepping out from behind the counter and into the clinical command center. This is where your drug expertise transforms from a verification service into a critical component of real-time medical decision-making.

SECTION 23.1

What Rounds Look Like: A Deep Dive

Decoding the daily ritual that shapes patient care and defines the role of the modern hospital pharmacist.

23.1.1 The “Why”: From Dispensing Cell to Clinical Council

In your years of practice, you have become an undisputed expert in the final, critical moments of the medication use process. You are the ultimate gatekeeper, the final checkpoint ensuring that the right drug, in the right dose, gets to the right patient. You have saved patients from countless errors, adverse events, and therapeutic misadventures through your meticulous verification process. Now, imagine taking that same expertise and applying it not at the end of the process, but right at the very beginning—at the exact moment a therapeutic decision is being made. That is the essence of patient care rounds.

Joining the medical team on rounds represents the most significant mental and professional shift in the transition from community to hospital pharmacy. You are moving from a respected but physically separate consultant to an integrated, front-line member of a multidisciplinary team. Your role is no longer reactive; it becomes profoundly proactive. Instead of questioning an inappropriate dose after it has been prescribed, you are there to prevent it from ever being ordered. Instead of identifying a drug interaction after the fact, you are there to guide the team toward a safer alternative from the outset. You are no longer just a drug expert; you are the team’s drug therapy strategist.

The Pharmacist’s Value Proposition on Rounds: A Multifaceted Impact

The presence of a pharmacist on rounds is not a luxury; it is a proven, evidence-based intervention that dramatically improves patient safety and clinical outcomes. Your value is demonstrated in a continuous loop of real-time contributions:

  • Real-Time Medication Safety Sentinel: This is the most direct translation of your retail skills. You are listening to the patient presentation, reviewing labs, and cross-referencing the proposed plan against the patient’s allergies, organ function, and existing medications. You are the safety net, catching potential errors related to dosing, drug selection, therapeutic duplication, and interactions in real time.
  • Pharmacokinetic & Pharmacodynamic Optimization: You are the expert in how drugs behave in the body. On rounds, this knowledge becomes dynamic. You will recommend loading doses for antibiotics to achieve rapid therapeutic concentrations, adjust vancomycin dosing based on a fresh trough level, and advise on the timing of diuretics relative to blood pressure medications to maximize efficacy and minimize side effects.
  • Antimicrobial Stewardship Champion: You are the team’s conscience for appropriate antibiotic use. This involves recommending de-escalation of therapy based on culture results, ensuring appropriate durations of therapy, and guiding the selection of the narrowest-spectrum, most effective agent to combat resistance.
  • Cost-Effective Therapy Advocate: With your deep knowledge of the hospital formulary, you can guide the team toward therapies that are not only clinically effective but also financially responsible. This could involve recommending an equally effective but less expensive antibiotic, transitioning a patient from IV to PO therapy sooner, or identifying therapeutic alternatives for non-formulary medications.
  • Transition of Care Architect: The discharge plan begins on the day of admission. On rounds, you are already thinking ahead. You identify potential barriers to a safe discharge, such as a complex insulin regimen for a patient with low health literacy or a new, expensive anticoagulant for a patient with no prescription drug coverage. You are the one who asks, “How will the patient manage this at home?” and starts the process of patient education and medication access support long before the discharge order is written.

This shift is profound. You are moving from the product to the patient, from the prescription to the plan. Your encyclopedic drug knowledge, which was once used to validate decisions, is now used to shape them.

Retail Pharmacist Analogy: The Ultimate, Proactive DUR

Imagine a patient’s primary care physician, their cardiologist, and their endocrinologist are all standing in your pharmacy, in front of your computer, discussing what to prescribe next for their complex mutual patient. The PCP suggests starting a high-dose NSAID for pain. Before they can even finish the sentence, you, pointing to the screen, say, “Hold on, remember he’s on warfarin from the cardiologist for his A-Fib and his last INR was already 2.8. An NSAID will significantly increase his bleed risk. Also, his renal function is borderline, and this could tip him into an AKI. For his type of pain, let’s consider starting with scheduled acetaminophen and maybe a topical agent.”

The endocrinologist then suggests starting a new SGLT2 inhibitor. You immediately add, “Great idea for his cardiovascular risk, but let’s make sure we counsel him thoroughly on the signs of euglycemic DKA and the importance of holding it if he feels unwell, especially with his history of poor oral intake when he’s sick.”

That meeting? That is rounds.

In retail, you would have received these prescriptions piecemeal, after the decisions were made. You would have seen the NSAID prescription, recognized the danger, and had to place a call, hoping to catch the doctor, explain the situation, and recommend an alternative. On rounds, you are in the “room where it happens.” You are not correcting a decision; you are co-creating a safer, more effective one from the very beginning. Your intervention is immediate, collaborative, and infinitely more impactful. You already have all the clinical knowledge to do this; rounds just give you a new, more powerful venue to apply it.

23.1.2 The Two Worlds of Rounds: Teaching vs. Non-Teaching Services

While the goal of rounds is always the same—to review patient status and establish a plan of care—the format, pace, and personnel can vary dramatically. The most significant dividing line in the hospital ecosystem is whether you are on a “teaching” service or a “non-teaching” service. Understanding the culture, expectations, and communication styles of each is the first step to becoming an effective clinical pharmacist. They are two fundamentally different worlds, each requiring a distinct approach to be successful.

Deep Dive: The Teaching Service (The “Academic” Model)

Often found in academic medical centers and larger community hospitals with residency programs, teaching services are the training grounds for the next generation of physicians. The care team is a complex, hierarchical structure of learners at various stages, all under the supervision of a single, experienced physician. The pace can be slower and more deliberate, as every patient encounter is a potential learning opportunity. For the pharmacist, this environment is rich with opportunities to educate and influence, but it also demands patience and a nuanced understanding of the team’s structure.

The Cast of Characters: Decoding the Hierarchy

Successfully navigating teaching rounds requires knowing who’s who, what their role is, and what their primary motivations are. Think of it as a cast in a play, each with a specific part to perform.

Team Member Typical Title Primary Role & Responsibilities How to Interact as a Pharmacist
The Leader & Final Authority Attending Physician Bears ultimate legal and clinical responsibility for every patient. Their primary goals are patient safety, resident education, and efficient team management. They guide the discussion, ask probing questions to test the residents’ knowledge, and make the final call on all major decisions. Show deference and respect. Address major recommendations directly to them, or to the senior resident with the attending present. Be prepared to back up your suggestions with evidence, as they may challenge you for teaching purposes.
The Team Manager Senior Resident (PGY-2 or PGY-3) The day-to-day team leader. They supervise the interns, organize the patient list, lead the presentations on rounds, and are the first to field questions and formulate plans. They are focused on both patient care and managing their junior learners. This is often your strongest ally and primary point of contact. Discuss routine issues with them pre-rounds. On rounds, they are often the person you will direct your initial comments to. Building a strong rapport with the senior resident is key to an effective rotation.
The Front-Line Worker Intern (PGY-1) The first-year resident. They are responsible for a specific set of patients and know every detail about them. They perform the initial workup, write the daily progress notes, enter all the orders, and call consults. They are often sleep-deprived and overwhelmed but are sponges for practical knowledge. Be their guide and safety net. When they present, listen closely for small errors or omissions. Offer helpful, non-judgmental corrections. They are incredibly receptive to practical tips like “Don’t forget to re-order the home statin” or “The standard Zosyn dose needs to be renally adjusted for this patient.”
The Learner Medical Student (MS3 or MS4) The most junior member of the team. They typically follow one or two patients in extreme detail. Their job is to learn how to think like a doctor. They have a vast knowledge of textbook pathophysiology but often lack practical clinical experience. Be a teacher. When they present, they may not know common drug doses or monitoring parameters. Use their questions as an opportunity to explain a concept to the whole team (e.g., “That’s a great question about why we use ceftriaxone for this. It has excellent coverage for Strep pneumo and doesn’t require renal adjustment…”).
The Rhythm and Flow of Teaching Rounds

Teaching rounds are a highly structured, often lengthy ritual. While the exact format varies, it typically follows a predictable pattern.

  1. Pre-Rounds Preparation (The Pharmacist’s Homework): This is arguably the most important part of your day. It happens hours before the team meets. You will systematically review every patient on the service, focusing on medication-related data:
    • Labs: Reviewing morning labs is critical. You’re looking for changes in renal/hepatic function (requiring dose adjustments), electrolyte abnormalities, out-of-range drug levels (vancomycin troughs, INRs), and infection markers (WBC, CRP).
    • Medication Administration Record (MAR): Did the patient receive all their doses? Did they require a lot of PRN pain or anxiety medication overnight? Were there any missed doses?
    • New Orders: Review any new orders placed overnight. Are they appropriate? Do they need clarification?
    • Reviewing Notes: Quickly scan the overnight resident and nursing notes for any clinical events (e.g., a hypotensive episode, a new-onset fever).
    • Formulating a Plan: For each patient, you should have your own “SOAP” note in your head, focused on medications. You should anticipate the team’s needs and have your recommendations ready before they even ask.
  2. The Huddle (Running the List): The team gathers briefly before starting. The senior resident will quickly go through the patient list, identify who is the sickest and needs to be seen first, and note any planned discharges or new admissions. This is your chance to flag any urgent overnight medication issues (“Just a heads up, Mrs. Smith’s vancomycin trough came back critically high at 45. We need to hold her dose.”).
  3. Walking Rounds (The Main Event): The team moves from room to room. Typically, they will stop outside the patient’s room for the formal presentation to avoid lengthy discussions in front of the patient and family.
  4. The Presentation: The intern or medical student will present the patient in a structured format, often a variation of SOAP. They will start with a one-liner (“Mr. Davis is a 68-year-old male with a history of CAD and diabetes, here for community-acquired pneumonia, now on hospital day 3.”), followed by subjective updates, a review of vitals, objective data (labs, imaging), and then a formal Assessment and Plan, broken down by organ system or problem.
  5. Your Role During the Presentation: Listen intently. The “Plan” portion is your primary engagement zone. When the intern gets to the part about “GI/Prophylaxis” or “Infectious Disease,” that’s your cue. Let them finish their proposed plan, and then, in the pause that follows, you can offer your input.
  6. Entering the Room: After the presentation and discussion, the team (or a subset of the team) will go into the room to examine the patient, ask questions, and provide updates. This is a time for listening, not for detailed medication discussions unless a specific question is asked directly.

Deep Dive: The Non-Teaching Service (The “Efficiency” Model)

Found in many community hospitals and increasingly common in all settings, non-teaching services are typically run by an attending physician (often a “hospitalist”) who may work with Advanced Practice Providers (APPs) like Nurse Practitioners (NPs) or Physician Assistants (PAs). There are no learners. The entire focus is on providing safe, high-quality, and efficient patient care. Rounds are often faster, more direct, and less formal. Your role here is less of a teacher and more of a highly valued, rapid-response consultant.

The Cast of Characters: A Leaner Team
Team Member Primary Role & Responsibilities How to Interact as a Pharmacist
The Leader & Doer Hospitalist or Specialist Attending This physician is the primary decision-maker and also the primary worker. They are managing a list of patients with a relentless focus on diagnosis, treatment, and disposition (i.e., getting the patient safely discharged). They value concise, actionable information. Be direct, be prepared, and be brief. They don’t have time for a lengthy explanation of a drug’s mechanism of action. Lead with your recommendation. “Dr. Jones, for Mr. Williams in 301, I recommend we switch his IV levofloxacin to oral. He’s meeting criteria.”
The Collaborator Advanced Practice Provider (NP/PA) APPs are highly skilled clinicians who often manage their own subset of patients in collaboration with the physician. They are frequently responsible for writing daily notes, entering orders, and coordinating care. APPs are often incredible pharmacist allies. They are highly collaborative and very receptive to pharmacist input. Build a strong working relationship with them. You can often address many medication issues directly with the APP, who will then implement the plan.
The Rhythm and Flow of Non-Teaching Rounds

The ritual of “walking rounds” is often replaced by a more efficient model designed to get through the patient list quickly and create actionable plans.

  • The Format (“Table Rounds”): The team—physician, APP, pharmacist, and sometimes a case manager or charge nurse—gathers in a conference room or at a computer workstation. They will go through the entire patient list one by one, often without physically going to the bedside as a group.
  • The Presentation (The “Update”): There is no formal SOAP presentation. The physician or APP will pull up the patient’s chart on a large screen and give a very brief summary: “Okay, Mrs. Green in 512. Admitted for heart failure exacerbation. She got 80 of IV Lasix overnight, netted negative 2 liters. Breathing is much better. Morning labs look stable. Plan is to continue diuresis and get an echo today. Any issues?”
  • Your Role (Rapid-Fire Response): The question “Any issues?” is your direct invitation to speak. Your pre-rounds preparation is even more critical here because you have only a few seconds to make your point. Your interventions must be concise and clinically significant. “Yes, her potassium is down to 3.1 this morning after the diuresis. I recommend we give 40 mEq of oral potassium now.” There is no time for long-winded explanations unless you are asked. The goal is to identify a problem and offer a clear solution in the same breath.
Comparing the Two Worlds: A Head-to-Head Summary
Feature Teaching Service (“Academic Model”) Non-Teaching Service (“Efficiency Model”)
Pace Slow, deliberate, methodical. Fast, rapid-fire, to-the-point.
Primary Goal Patient care AND education. Efficient and safe patient care and disposition.
Format Often “walking rounds,” with formal presentations outside patient rooms. Often “table rounds” in a conference room with abbreviated updates.
Pharmacist’s Role Educator, safety net, influencer of future prescribers. Expert consultant, problem-solver, efficiency-driver.
Communication Style More formal, often involves Socratic questioning, explanations are encouraged. Informal, direct, shorthand is common. Lead with the answer.
Key to Success Patience, ability to teach, understanding of team hierarchy. Thorough preparation, confidence, extreme conciseness.

Retail Pharmacist Analogy: Precepting a Student vs. Working with Your Best Technician

Think about the difference in your workflow and communication style on two different days in your pharmacy.

On Monday, you are precepting a new pharmacy student. This is Teaching Rounds. When a prescription for metformin comes in, you don’t just check it. You pull the student aside. You ask them, “What’s the starting dose? What are the key counseling points? What labs should we check? Why is this contraindicated in severe renal impairment?” You use the prescription as a teaching tool. The process is slower, more Socratic, and focused on building the student’s knowledge base.

On Tuesday, your best, most experienced technician is working with you. This is Non-Teaching Rounds. When the same metformin prescription comes in, you see it on the screen. Your technician has already filled it. You look at them, they look at you, and you just say, “Metformin for Mrs. Jones, looks good.” They nod. The entire communication is condensed into a few seconds of mutual understanding and trust. You don’t need to explain the ‘why’; you are both focused on the ‘what’ and getting it done safely and quickly. You trust their competence, and they trust your clinical judgment. That is the essence of communication on a non-teaching service: professional, direct, and built on a foundation of shared expertise.