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MODULE 23: CLINICAL PHARMACY ON THE FLOORS: MASTERING PATIENT CARE ROUNDS
Section 23.8: Post-Round Follow-Through: Notes, Tasks, and Handoffs
This is where recommendations become reality. Mastering the art of implementation, documentation, and communication to ensure seamless, 24/7 pharmaceutical care.
SECTION 23.8
Post-Round Follow-Through: A Deep Dive
This is your masterclass on transforming the decisions made on rounds into tangible actions that protect patients and drive positive outcomes.
23.8.1 The “Why”: Closing the Loop Between Decision and Action
The intellectual heavy lifting of your day often happens before and during rounds. The pre-round preparation is your investigation, and your participation on rounds is your presentation of the evidence. However, if the process stops there, you have accomplished nothing for the patient. A brilliant recommendation that is agreed upon by the team but never actually implemented is a clinical failure. The post-round period is where the kinetic energy of decision-making is converted into the potential energy of patient safety. It is the crucial, and often unglamorous, work of “closing the loop.”
This phase of your day is governed by a simple, powerful principle: a patient’s care should never be delayed or compromised because of a breakdown in implementation or communication. The orders agreed upon must be entered correctly. The necessary follow-up labs must be scheduled. The critical information about a patient’s therapy must be documented clearly for every clinician to see. The plan for monitoring a high-risk drug must be seamlessly handed off to the evening and night shift pharmacists. Without a systematic approach to this follow-through, even the best rounding service can be undermined by dropped balls and missed details.
Mastering the post-round workflow is what makes you a reliable and trusted clinician. It demonstrates to the team that when you make a recommendation, you take ownership of it from conception to completion. It proves that you are not just a consultant who offers advice, but an active, accountable member of the team dedicated to ensuring the care plan is executed safely and effectively, 24 hours a day, 7 days a week.
Retail Pharmacist Analogy: The Full Prescription Lifecycle
This entire module can be viewed through the lens of a single, complex prescription in your retail pharmacy.
- Pre-Rounds Preparation is the work you do when a prescription first enters your queue. You perform the data entry, review the patient’s profile, and identify a significant drug interaction (a DUR rejection). You do the research and identify the problem and a potential solution.
- Participating on Rounds is the clarification call you make to the prescriber. You present the problem (the interaction), explain your assessment (the risk to the patient), and provide a recommendation (a safer alternative drug). The prescriber agrees with your recommendation. This is the decision.
- Post-Round Follow-Through is everything that happens *after* you hang up the phone. It is the real work. You have to update the prescription in the computer, transmit the claim to the insurance, pull the correct drug, count it accurately, label the bottle, have it verified, and finally, counsel the patient. Without these crucial implementation steps, the brilliant clarification call was pointless. The patient still wouldn’t have their medication. This follow-through is the essence of your post-round responsibilities.
23.8.2 The Pharmacist’s Post-Round Workflow: A Systematic Approach
The moments immediately following the conclusion of rounds can feel chaotic. Multiple action items for multiple patients are fresh in your mind. A structured workflow is essential to ensure that nothing is missed. This four-step process provides a reliable framework to bring order to the post-round period.
The 4-Step Post-Round Execution Plan
1
Debrief & Prioritize (The First 5 Minutes)
Immediately after rounds, before you do anything else, find a quiet spot and take five minutes to review your rounding notes (“cheat sheet”). Use a highlighter or a star system to triage your pending tasks into three categories:
- Urgent/Safety-Critical: These must be done NOW. Examples: Discontinuing a harmful drug, ordering Vitamin K for a high INR, pending a STAT antibiotic dose.
- Standard/Important: These should be done soon, typically within the first hour post-rounds. Examples: Writing your clinical notes, routine dose adjustments, IV-to-PO conversions.
- Non-Urgent/Follow-up: These can be done later in the day. Examples: Following up on non-critical labs, preparing discharge counseling materials.
2
Execute & Document (The First Hour)
Work through your prioritized list, starting with the urgent tasks. As you complete each action, physically check it off your list. This is also the prime time to write your clinical progress notes in the EHR. Documentation is not an afterthought; it is part of the execution.
3
Monitor & Re-evaluate (Mid-day Check-in)
Your work on a patient is not “done” after the first hour. Set aside time in the early afternoon to circle back on your patients. Have any new, significant lab values resulted? Have any drug levels you ordered been drawn? Has a patient’s clinical status changed? This mid-day check is what allows you to be proactive rather than reactive to new information.
4
Synthesize & Handoff (End of Shift)
In the last 30 minutes of your shift, review your patient list one final time. What tasks are still pending that the next pharmacist needs to be aware of? Synthesize this information into a clear, concise handoff report. This ensures the continuity of pharmaceutical care after you leave.
23.8.3 Masterclass on Clinical Documentation: The High-Impact Pharmacy Note
A progress note in the EHR is not just a task to be completed; it is a powerful communication tool. It is your opportunity to formally document your cognitive work, articulate your assessment of a patient’s pharmacotherapy, and clearly outline your plan. A well-written note serves several critical functions: it communicates your plan to the entire care team (including consultants and covering physicians who were not on rounds), it serves as a legal record of your involvement, and it is a primary way that pharmacy leadership can quantify your clinical value.
The most widely used and effective format for clinical notes is the SOAP note. While you may use variations, its structure provides a logical flow from data to action.
Deconstructing the Pharmacist’s SOAP Note
| Component | Purpose & Content | Example |
|---|---|---|
| S (Subjective) | What the patient (or their family/nurse) tells you. For pharmacists, this is often brief and focused on medication-related issues. Many pharmacy notes omit this section if there is no subjective information to report. | “Patient reports his pain is well-controlled on the current regimen.” OR “Patient complains of nausea approximately 1 hour after each dose of oral tramadol.” |
| O (Objective) | Hard data. This is where you list the key vital signs, lab values, culture results, or drug levels that support your assessment. This is NOT a data dump of all the day’s labs. It should be a curated list of only the relevant findings. | “SCr 2.5 (up from 1.8 yesterday). CrCl (CG) est. 25 mL/min. K+ 3.2. Vancomycin trough 24.5 mcg/mL. WBC 11.5 (down from 15).” |
| A (Assessment) | Your clinical brain at work. This is the most important section. You connect the S and O to form a conclusion about each medication-related problem. Number each problem for clarity. | “1. Acute Kidney Injury: Worsening renal function likely contributing to supratherapeutic vancomycin level. 2. Hypokalemia: Likely secondary to aggressive diuresis. Requires replacement. 3. Pain Control: Patient’s pain appears to be adequately controlled on current regimen.” |
| P (Plan) | Your specific actions and recommendations, numbered to correspond with your assessment points. This section should be clear, concise, and actionable. State what you did, what you will do, and what you recommend. | “1. AKI/Vanc: Recommended holding next dose of vancomycin and re-dosing at 1g IV q48h based on PK calculations. Discussed with Dr. Smith, who agreed. Order pended. Will re-check random level tomorrow. 2. Hypokalemia: Recommended 40mEq of oral potassium chloride x1 dose. Order placed. 3. Pain: Continue current regimen. Monitor for side effects.” |
The Pitfall of the “Book Report” Note
The most common mistake in documentation is writing a note that simply summarizes what the medical team is doing without adding any unique pharmacy perspective. A note that says “Patient admitted for pneumonia. Plan to continue IV antibiotics” is a worthless note. It adds no value. Your note must focus on YOUR assessments and YOUR actions. It should answer the question: “What did the pharmacist do for this patient today?”
23.8.4 Masterclass on Executing Pharmacokinetic Consults
One of your most frequent and high-stakes post-round tasks will be managing therapeutic drug monitoring, especially for vancomycin. The move away from trough-based monitoring to Area Under the Curve (AUC)-based monitoring is the current standard of care, and your ability to perform these calculations is a key differentiator of your expertise.
The goal for vancomycin in serious MRSA infections is to achieve a 24-hour AUC to MIC ratio (AUC/MIC) of 400-600 to maximize efficacy while minimizing the risk of nephrotoxicity. We assume an MIC of 1 for calculations.
Playbook: Two-Level Pharmacokinetic Dosing Adjustment
This method uses two drug levels (a peak and a trough, or two random levels) to calculate patient-specific pharmacokinetic parameters.
Vancomycin AUC Dosing Case Study
Mr. Johnson is a 70 y/o, 80kg male receiving vancomycin 1500mg IV q12h for MRSA bacteremia. His SCr is stable at 1.1 mg/dL. The team asks you to manage the dosing. You order two levels around the 4th dose: a level 2 hours after the infusion ends (Cpk) and a level 30 minutes before the next dose (Ctr).
Results: Cpk = 32.5 mcg/mL, Ctr = 14.8 mcg/mL.
- Step 1: Calculate the Elimination Rate Constant (ke)
The `ke` represents the fraction of drug eliminated per unit of time. It’s calculated from the slope of the line between your two levels.
$$ ke = \frac{\ln(C_1) – \ln(C_2)}{\Delta t} $$
Where C1 is the first level (32.5), C2 is the second level (14.8), and Δt is the time between the levels. If the dose interval is 12 hours and the infusion is 2 hours, the time between levels is 12 – 2 – 0.5 = 9.5 hours.
$$ ke = \frac{\ln(32.5) – \ln(14.8)}{9.5 \text{ hr}} = \frac{3.48 – 2.70}{9.5} = 0.082 \text{ hr}^{-1} $$
- Step 2: Calculate the Volume of Distribution (Vd)
First, extrapolate the true peak (at the end of infusion) and true trough (at the time of the next dose).
$$ C_{peak,true} = C_{pk,measured} \times e^{(ke \times t_{since_infusion})} = 32.5 \times e^{(0.082 \times 2)} = 38.3 \text{ mcg/mL} $$
$$ C_{trough,true} = C_{tr,measured} \times e^{-(ke \times t_{before_dose})} = 14.8 \times e^{-(0.082 \times 0.5)} = 14.2 \text{ mcg/mL} $$
Now, calculate Vd.
$$ Vd = \frac{\text{Dose} / \text{Infusion Time}}{ke \times C_{peak,true} – C_{trough,true} \times e^{-(ke \times \text{Infusion Time})}} \times (1 – e^{-(ke \times \text{Infusion Time})}) $$
$$ Vd = \frac{1500 / 2}{0.082 \times 38.3 – 14.2 \times e^{-(0.082 \times 2)}} \times (1 – e^{-(0.082 \times 2)}) \approx 55 \text{ L} $$
- Step 3: Calculate the 24-hour AUC
AUC for a single dose is simply Dose / (ke * Vd). Total daily dose is 3000mg.
$$ AUC_{24} = \frac{\text{Total Daily Dose}}{\text{Clearance}} = \frac{\text{Total Daily Dose}}{ke \times Vd} $$
$$ AUC_{24} = \frac{3000 \text{ mg}}{(0.082 \text{ hr}^{-1}) \times (55 \text{ L})} = 665 \text{ mg*h/L} $$
- Step 4: Assess and Recommend
The calculated AUC of 665 is above the goal range of 400-600. The dose is too high.
Your recommendation: “Based on patient-specific kinetics, the current vancomycin regimen is producing a supratherapeutic AUC of 665, increasing the risk of nephrotoxicity. I recommend we reduce the dose to 1250mg IV q12h, which is predicted to achieve a goal AUC of ~550. I will pend the order and we can re-check levels in 2-3 days.”
23.8.5 Masterclass on The Art of the Handoff: Ensuring Seamless Care
No pharmacist works in a vacuum. The care you provide during your shift must be seamlessly continued by your colleagues in the evening and overnight. A poor handoff is a gaping hole in the patient safety net. It can lead to missed lab follow-ups, delayed dose adjustments, or a failure to act on critical new information. The goal of a handoff is not to re-tell the patient’s entire story, but to provide a concise, action-oriented summary of pending tasks and anticipated events.
The “IPASS” Framework for Pharmacy Handoffs
IPASS is an evidence-based mnemonic that provides a reliable structure for handoffs.
| Component | Pharmacist’s Focus | Example |
|---|---|---|
| I – Illness Severity | A brief one-liner to orient the oncoming pharmacist. Is this patient stable, a “watcher,” or critically ill? | “Stable patient for discharge tomorrow.” OR “Critically ill patient in septic shock, on multiple pressors.” |
| P – Patient Summary | A very brief summary of the patient’s story and primary medication-related issues being followed. | “65 y/o male with MRSA bacteremia, currently managing vancomycin dosing in the setting of AKI.” |
| A – Action List | What did you do today? A very brief summary of your key interventions. | “Dose-adjusted vancomycin per kinetics, recommended potassium replacement, de-escalated antibiotics.” |
| S – Situational Awareness & Contingency Planning | This is the most critical part. What do you anticipate might happen, and what should the next pharmacist be watching for? This is the “if-then” planning. | “His potassium was low; we repleted it, but he is on a Lasix drip, so please re-check the 8 PM lab value. **If** it’s still < 3.5, he will need more potassium. **If** his BP continues to drop, the team may ask for pressor recommendations." |
| S – Synthesis by Receiver | The oncoming pharmacist should briefly summarize the plan back to you to ensure there is a shared mental model. | “Okay, so for Mr. Smith, I’ll check the 8 PM potassium and replete if needed, and I’ll keep an eye on his blood pressure. Got it.” |
Focus on the Unfinished.
The golden rule of handoff is to focus on what is pending. The oncoming pharmacist can read your note to see what you’ve already completed. Your verbal or written handoff should be almost exclusively dedicated to things that require future action or monitoring. Always ask yourself: “What does my colleague absolutely need to know to safely care for this patient overnight?”
- “Pending vancomycin level from 1800 draw.”
- “INR needs to be re-checked with morning labs.”
- “Patient is getting their first dose of warfarin tonight; please ensure it’s verified promptly.”
- “Team is waiting on blood culture results, may need to broaden antibiotics overnight if he spikes a fever.”
