CHPPC Module 23, Section 2: Pre-Round Prep
MODULE 23: CLINICAL PHARMACY ON THE FLOORS: MASTERING PATIENT CARE ROUNDS

Section 23.2: Pre-Round Prep: The Pharmacist’s “Cheat Sheet”

How to build a systematic, repeatable process for data gathering that transforms you from a spectator into an indispensable contributor on rounds.

SECTION 23.2

Pre-Rounds Preparation: A Deep Dive

The secret to a stellar performance on rounds happens hours before the team ever assembles. This is your masterclass in preparation.

23.2.1 The “Why”: The Power of the Prepared Mind

In the previous section, we established that rounds are the hospital’s clinical command center, a dynamic environment where real-time decisions shape patient outcomes. We also established that the pace can be unforgiving, especially on non-teaching services. The medical team comes to rounds having already seen their patients, reviewed overnight events, and formulated a preliminary plan. If you walk into that environment “cold,” without having done your own deep dive into the patient’s data, you are, by definition, several steps behind everyone else in the room. You are immediately relegated to a reactive role, a spectator who might occasionally be asked a question. This is the antithesis of a clinical pharmacist’s purpose.

Effective participation on rounds is not a test of your ability to recall random facts from memory. It is a demonstration of your ability to systematically gather, interpret, and synthesize patient-specific data to identify and solve medication-related problems. The quality of your interventions is directly and inescapably proportional to the quality of your preparation. A well-prepared pharmacist walks into rounds not with a blank slate, but with a fully formed, evidence-based opinion on the medication therapy for every single patient on the list. You are not there to learn the plan; you are there to help refine it, optimize it, and safeguard it.

This dedicated preparation time—often referred to as “working up patients”—is the most critical, value-adding activity in your clinical day. It is the foundation upon which your entire clinical impact is built. Without it, even the most knowledgeable pharmacist is rendered ineffective. With it, you become an indispensable asset, anticipating needs, identifying risks the team may have missed, and bringing clear, actionable solutions to the table.

Retail Pharmacist Analogy: The Monday Morning Refill Rush

Imagine it’s Monday morning at 9:05 AM in your retail pharmacy. The weekend queue is filled with 75 prescriptions. Dr. Smith’s office just sent over 15 new electronic prescriptions. The phone is ringing with a transfer request. A patient is at the counter with a complex insurance problem.

Now, consider two scenarios.

Scenario A (Unprepared): You dive right in, clicking on the first prescription in the queue and trying to solve problems as they appear. You’re constantly switching tasks, trying to remember details about the insurance issue while verifying a new script, all while the phone rings. Your workflow is chaotic and stressful. You are purely reactive.

Scenario B (Prepared): Before touching a single prescription, you take three minutes to strategize. You quickly scan the entire queue. You group all of Dr. Smith’s prescriptions together to check them cohesively. You print out the prescriptions that need a CII from the safe so you can get them all at once. You hand the insurance problem to your best technician with clear instructions. You see the transfer request and set it aside to handle after the initial rush. You have created a system. You have identified and triaged your problems before they overwhelm you. Your workflow is calm, efficient, and proactive.

Pre-rounding is Scenario B. It’s the dedicated time you take before the “rush” of rounds begins to organize the chaos. It allows you to systematically identify every potential medication-related issue so that when you’re “live” with the team, you’re not flustered or caught off guard. You’re executing a well-thought-out plan, just as you do every day in the pharmacy.

23.2.2 The “5-Box” Cheat Sheet: A Framework for Systematic Data Collection

The human brain is not designed to hold dozens of disparate data points for 15-20 complex patients in short-term memory. Attempting to do so is a recipe for error and missed opportunities. The key to effective pre-rounding is to offload that data from your brain onto a structured, organized tool. This tool, often called a “cheat sheet,” “patient workup form,” or “rounds notes,” becomes your external brain for the day.

While many variations exist, one of the most effective and widely adopted frameworks is the “5-Box” System. This method forces you to organize patient information into five distinct, logical categories. It transforms the sprawling, often chaotic electronic health record (EHR) into a concise, medication-focused snapshot for each patient. Whether you use a printed template, a digital document, or just a blank piece of paper divided into sections, adhering to this structure ensures you don’t miss critical information.

Visualizing the 5-Box Framework

Patient: [Patient Name/MRN/Room]

1. ID / Demographics
  • Age, Sex, Weight (kg), Height
  • Allergies & Reaction Type
  • Code Status (e.g., Full Code, DNR/DNI)
2. Dx / Plan
  • Reason for Admission
  • Active Problem List
  • Overall Goal (e.g., Diuresis, IV abx, discharge planning)
3. Medications
  • Inpatient Meds: Focus on new starts, high-risk drugs, PRN usage.
  • Home Meds: Note reconciliation status (continued, held, discontinued).
  • Antimicrobials: Drug, dose, day of therapy.
4. Labs / Vitals
  • Vitals: Fever curve, BP/HR trends, O2 sat.
  • Labs: Chem7, CBC, LFTs, Coags, Drug Levels.
  • Micro: Culture sources & results.
5. Issues / To-Do List
  • Your action items. The synthesis of all above boxes.
  • Renal dose adjust abx?
  • Recommend K+ replacement?
  • IV to PO candidate?
  • Therapeutic duplication?

This structure is powerful because it creates a consistent mental workflow. For every patient, every single day, you will follow the same pattern of data collection. This repetition builds expertise and efficiency, ensuring that even on your busiest days, the fundamental safety checks are never missed.

23.2.3 Masterclass on the 5 Boxes: What to Look For and Why

Now, let’s perform a deep dive into each box. We will explore not just *what* data to collect, but *why* that data is critically important from a pharmacotherapy perspective, and what common red flags you should be searching for.

Box 1: ID / Demographics – The Foundational Identifiers

This box seems basic, but it contains foundational data that influences countless downstream decisions. Getting this right prevents fundamental errors.

Data Point Pharmacist’s Clinical Significance & Common Pitfalls
Age, Sex Age is a critical factor in renal function estimation (e.g., Cockcroft-Gault) and risk assessment for certain drugs (e.g., Beers Criteria for elderly patients). Sex can influence dosing for some medications and interpretation of lab values.
Weight (in kg) & Height This is one of the most critical pieces of information. Countless medications are dosed based on weight (mg/kg).
  • Always use kilograms. Convert from pounds if necessary (lbs / 2.2 = kg).
  • Actual vs. Ideal vs. Adjusted Body Weight: Which weight to use is drug-specific and a common source of error, especially in obese patients. For example, aminoglycosides are often dosed on adjusted body weight, while many chemo drugs use actual. This is a key area for pharmacist intervention.
  • Pitfall: An inaccurate documented weight can lead to significant dosing errors. If a patient’s weight seems inconsistent with their appearance, flag it for confirmation.
Allergies & Reaction Type Your expertise as a pharmacist is vital here. You must go beyond the documented allergy list.
  • “What was the reaction?” This is the most important question. A documented “penicillin allergy” that was a mild rash 20 years ago has a very different clinical implication than one that caused anaphylaxis. A “codeine allergy” that was just nausea is likely an intolerance, not a true allergy, and doesn’t preclude the use of other opioids.
  • Cross-Reactivity: You are the expert on cross-reactivity (e.g., between penicillins and cephalosporins, or between sulfonamide antibiotics and other sulfa-containing drugs). The team will rely on you to assess this risk.
  • Pitfall: Accepting the documented list at face value. Always strive to clarify the nature of the reaction.
Code Status This informs the overall goals of care. In a patient who is DNR/DNI (Do Not Resuscitate/Do Not Intubate), the focus may shift from aggressive life-prolonging measures to comfort and symptom management. This can influence decisions about starting or stopping certain medications (e.g., it may not be appropriate to start a statin for primary prevention in a purely palliative care setting).

Box 2: Dx / Plan – The Clinical Context

You cannot evaluate the appropriateness of a medication without first understanding why the patient is in the hospital and what the medical team is trying to achieve. This box provides the narrative and the context for all your pharmacotherapeutic decisions.

Data Point Pharmacist’s Clinical Significance & Common Pitfalls
Reason for Admission This is the chief complaint, the primary diagnosis. It tells you the main reason for the current medication regimen. For a patient admitted with community-acquired pneumonia, you expect to see antibiotics. For a heart failure exacerbation, you expect to see diuretics.
Active Problem List This includes the primary diagnosis plus all other active medical issues, both acute (e.g., acute kidney injury, hypokalemia) and chronic (e.g., diabetes, hypertension, CKD). A core pharmacist function is to ensure that every active problem that warrants medication therapy is being appropriately treated, and that every medication on the profile has a corresponding indication on the problem list. This is the “indication-to-drug” and “drug-to-indication” cross-check.
Overall Goal / Plan What is the team’s objective for the day? This might be documented in the attending’s note or stated on rounds.
  • Examples: “Goal is to achieve a net negative fluid balance of 2 liters,” “Plan to transition to oral antibiotics today,” “Goal is to optimize pain control to allow for participation in physical therapy,” “Plan for discharge tomorrow if clinically stable.”
  • Significance: Knowing the goal allows you to align your recommendations. If the goal is diuresis, you should be proactively monitoring renal function and electrolytes. If the goal is discharge, you should be focusing on converting IV to PO meds, ensuring prescriptions are affordable, and planning for patient education.
  • Pitfall: Focusing only on a single drug without understanding its role in the larger plan. Your recommendations are most impactful when they help the team achieve its stated goals.

Box 3: Medications – Your Area of Ultimate Expertise

This is the most detailed and time-consuming part of your workup, and where you will find the majority of your interventions. A systematic approach is essential.

Medication Category Pharmacist’s Systematic Review Process
Scheduled Inpatient Medications For every single scheduled medication, ask yourself the “Big Four” questions:
  1. Is the indication appropriate? (Cross-reference with Box 2)
  2. Is the dose appropriate? (Consider organ function from Box 4, weight from Box 1, and the specific indication).
  3. Is the duration appropriate? (Especially for antibiotics and steroids).
  4. Is monitoring in place and appropriate? (Are there orders for drug levels, electrolyte checks, etc.?)
PRN (As Needed) Medications The MAR is your key tool here. Don’t just list the PRN meds; investigate their usage over the past 24 hours.
  • High PRN Opioid Use: If a patient is requiring multiple doses of PRN hydromorphone, their baseline pain is not well controlled. This is your cue to recommend a scheduled or long-acting analgesic.
  • High PRN Antiemetic Use: Is this due to opioids? Chemotherapy? Can the cause be addressed?
  • High PRN Sliding Scale Insulin Use: This indicates that the patient’s basal/bolus insulin regimen is inadequate and needs adjustment.
  • No PRN Usage: If a patient has an order for PRN docusate but hasn’t received it in 3 days, this could be a sign of a looming constipation problem, especially if they are on opioids.
Home Medications & Reconciliation This is a high-risk area for error. Your job is to be the ultimate auditor of the medication reconciliation.
  • Continued Meds: Were all appropriate chronic medications (statins, antihypertensives, antidepressants) correctly continued on admission?
  • Held Meds: Was there a clear and appropriate reason for holding a home medication (e.g., holding metformin in a patient with AKI and receiving IV contrast)? Your most important job is to ensure there is a plan to restart these medications once it is safe to do so. This is a common missed step.
  • Discontinued Meds: If a home medication was stopped, was it replaced with an appropriate alternative if needed?
High-Risk Medication Deep Dive Certain drug classes deserve special, focused attention every single day.
  • Antimicrobials: What is the drug, dose, and current day of therapy? Do culture results allow for de-escalation? Is the patient a candidate for IV to PO conversion?
  • Anticoagulants: Is the patient on the right drug for the right indication (prophylaxis vs. treatment)? Is the dose adjusted for renal function? Is appropriate monitoring (e.g., Anti-Xa, aPTT) being done? Is there a plan for bridging or restarting home anticoagulants?
  • Insulin & Glycemic Control: Review blood glucose trends. Is the patient experiencing hypoglycemia or persistent hyperglycemia? Is the sliding scale being used frequently?
  • Opioids & Sedatives: Is the patient’s pain/sedation adequately controlled? Are you monitoring for side effects (constipation, respiratory depression)? Is there a bowel regimen ordered?

Box 4: Labs / Vitals – The Objective Evidence

This box contains the objective data that validates your therapeutic plans. It’s where you find the evidence to support your recommendations for dose adjustments, new medications, or discontinuations. Your skill lies in identifying the most pertinent values and, more importantly, recognizing the trend over time.

Data Point Pharmacist’s Clinical Significance & Common Pitfalls
Renal Function (BUN, SCr) Your number one daily check. The trend is everything. Use it to calculate an estimated CrCl daily for every patient on renally-cleared drugs. A common pitfall is using an old calculation when the SCr has changed significantly.
Electrolytes (K, Mg, Na) Directly impacted by many drugs (e.g., diuretics, ACE inhibitors). Be proactive: if you start a diuretic, recommend electrolyte checks. A common pitfall is forgetting to check magnesium in cases of refractory hypokalemia.
CBC (WBC, Hgb, Plt) WBC: Key marker for infection response. Hgb/Hct: A drop can signal bleeding in patients on anticoagulants. Platelets: Monitor for drug-induced thrombocytopenia (e.g., from heparin).
Vitals (Temp, BP, HR) Temp: Fever curves are crucial for assessing antibiotic efficacy. BP/HR: Hypotension or bradycardia may be drug-induced. Hypertension may indicate uncontrolled pain or undertreated chronic disease.
Therapeutic Drug Levels The definition of pharmacist territory. Check levels (e.g., vancomycin trough, INR) every morning and be prepared with a specific dosing recommendation based on the result.
Microbiology The roadmap for antimicrobial stewardship. Check daily for new culture results and sensitivities. Use this data to recommend de-escalation from broad-spectrum agents to the narrowest, most effective therapy.

Box 5: Issues / To-Do List – The Action Plan

This is the most important box. It is the synthesis of all the data you have collected. It is where you connect the dots, converting your analysis into a concise, actionable plan. This is your script for rounds.

Purpose How to Use It Effectively
Synthesis & Action Plan This box is where you link data from one box to a medication in another to create a problem and a proposed solution. It should be a concise, bulleted list of your planned interventions, prioritized by clinical urgency. Each bullet point should be a complete thought that starts with the problem and ends with your recommendation.
Example Entries
  • “SCr up from 1.2 to 1.8. Patient on Zosyn 3.375g q6h. ACTION: Recommend renal dose adjustment to 2.25g q8h.”
  • “Blood culture from admission now growing MSSA. Patient on Vancomycin. ACTION: Recommend de-escalating to cefazolin.”
  • “Patient received 4 doses of PRN morphine overnight. ACTION: Recommend adding a scheduled long-acting opioid.”
  • “Potassium is 3.2. Patient is on Lasix. ACTION: Recommend 40mEq of oral potassium.”
  • “Home atorvastatin has been held for 3 days without a clear reason. ACTION: Recommend restarting.”