Psychiatry pre rounds what should we look and ask

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psychiatry pre-rounds checklist what to look for inpatient psychiatry

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I now have strong textbook material from Kaplan & Sadock's to build a comprehensive answer. Let me compile this into a practical pre-rounds guide.

Psychiatry Pre-Rounds: What to Look For and Ask

Pre-rounds in psychiatry are your chance to gather a focused snapshot of each patient before formal attending rounds. The goal is safety first, then symptom trajectory, then treatment progress. Here is a structured approach:

1. Review the Chart (Before Entering the Room)

Nursing notes overnight:

Any behavioral incidents (agitation, elopement attempts, verbal/physical altercations)
Use of PRN medications - what was given, when, and was it effective
Sleep: did the patient sleep? Refusal to sleep can signal mania or stimulant intoxication
Food/fluid intake and refusals
Code status and legal status (voluntary vs. involuntary)

Vital signs:

Fever (NMS, infection, serotonin syndrome)
Hypertension/tachycardia (alcohol withdrawal, stimulant use, anxiety)
Orthostatic changes (antipsychotic/antidepressant side effects)

Medications:

Was every dose taken (medication compliance documented)?
Any new PRNs or dose changes made overnight?
Lithium, clozapine, valproate levels - are any due today?
Labs needed: LFTs, CBC, metabolic panel, drug levels, UDS

Active orders:

Observation level (1:1, line of sight, 15-minute checks, unit restriction)
Any restraint or seclusion episodes

2. Enter the Room - The 2-Minute Scan

Before you ask a single question, observe:

What you see	What it suggests
Disheveled, malodorous, in bed	Decreased ADLs - depression, negative symptoms, decompensated psychosis
Pacing, pressured, can't sit still	Mania, akathisia, stimulant intoxication
Tremor, masked facies, shuffling	EPS from antipsychotics, Parkinson's
Tongue/mouth movements	Tardive dyskinesia
Tearful, withdrawn	Depression, PTSD, grief
Guarded, scanning the room	Paranoia, psychosis

3. The Pre-Rounds Interview - What to Ask

Keep this focused. You are not doing the full history again - you are tracking change from yesterday.

A. Safety Screen (ALWAYS first)

"Are you having any thoughts of hurting yourself or ending your life?"
"Are you having any thoughts of hurting anyone else?"
If suicidal: Are there a plan, intent, and means available? Has the thought gotten better or worse overnight?
Ask specifically about access to means - even on the inpatient unit

Per Kaplan & Sadock: "A regular suicide risk assessment should be carried out for patients who are at risk" and in acute crisis, focus should be on "reducing anxiety, insomnia, depression, and psychotic symptoms."

B. Sleep

"How did you sleep last night?"
Hours, continuity, nightmares (PTSD), nighttime wandering
Sleep is a key mood barometer - worsening insomnia often precedes a manic flip or suicidal escalation

C. Mood and Affect (patient-reported vs. observed)

"How are you feeling today compared to yesterday?"
Rate it: "On a scale of 1-10, how is your mood?"
Observe: is the reported mood congruent with the observed affect?

D. Psychotic Symptoms

"Are you still hearing voices? More, less, or the same as yesterday?"
"Are you feeling like people are out to get you?"
Track command hallucinations specifically - are they telling the patient to hurt themselves or others?

E. Medication

"Did you take all your medications last night and this morning?"
"Are you having any side effects?" - ask specifically about EPS (stiffness, restlessness), sedation, GI upset
Check if the patient actually swallowed tablets (cheeking is common in inpatient units)

F. Insight and Treatment Engagement

Does the patient know why they are here?
Are they willing to participate in groups and therapy today?
Any requests, complaints, or concerns about the treatment plan?

G. Physical Complaints

"Are you having any physical discomfort today?"
Psychiatric patients often have medical comorbidities that get missed
Ask about headache, chest pain, GI symptoms - can reflect medical deterioration, medication side effects, or somatic delusions

4. Quick Mental Status Snapshot

You do not need a full MSE at pre-rounds, but document the key domains:

Domain	What to note
Appearance	Grooming, dress, eye contact, psychomotor (agitated/retarded)
Speech	Rate (pressured/slowed), volume, coherence
Mood	Patient's own words in quotes
Affect	Range (full, restricted, flat, labile), congruence
Thought process	Linear, tangential, circumstantial, loose associations, flight of ideas
Thought content	SI/HI, delusions, paranoia, obsessions
Perception	Hallucinations (auditory, visual, tactile)
Cognition	Alert and oriented x3? Gross memory OK?
Insight	Does the patient understand they are ill?
Judgment	Can they make reasonable decisions about their safety and care?

Kaplan & Sadock's Synopsis of Psychiatry describes the mental status exam as offering "a cross-sectional view of how a patient thinks, feels, and behaves during the examination" - in pre-rounds, you are looking for deviation from yesterday's snapshot.

5. What to Report at Rounds

Structure your pre-rounds one-liner as:

"[Name], [age], [diagnosis], [admission day]. Overnight: [any incidents/PRNs]. This morning: mood [X/10], [MSE highlights], [safety status]. Plan concerns: [medication question, level due, discharge timing, etc.]"

For example:

"Mr. S, 34, bipolar I, day 3. Overnight required 2 mg lorazepam for agitation at 2 AM. This morning mood 4/10, affect still labile but less expansive, denies SI/HI, sleeping 4 hours. Lithium level due today - hasn't reached therapeutic range yet."

6. High-Priority Flags to Escalate Immediately

New or escalating suicidal ideation with plan/intent
New command hallucinations to harm
Signs of NMS: fever + rigidity + altered mental status + autonomic instability
Serotonin syndrome: hyperthermia + clonus + agitation (after recent medication changes)
Alcohol or benzo withdrawal: tremor, diaphoresis, tachycardia, seizure risk
Acute medical deterioration (fever, hypoxia, altered consciousness)
Elopement risk (patient expressing desire to leave against medical advice)

Summary Checklist

Nursing notes + vitals reviewed
Medication compliance and PRN use checked
Labs pending or due today noted
Safety (SI/HI) assessed
Sleep, mood, psychotic symptoms tracked vs. yesterday
Quick MSE done
Physical complaints addressed
Observation level appropriate?
One-liner ready for rounds

Sources: Kaplan & Sadock's Synopsis of Psychiatry (11e); Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Inpatient Hospitalization and Assessment sections.

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