Continued Care: Patient Rounds (Observation Checks)

Rounds, also known as bed checks or observations, are conducted by facility staff to document patients' locations and activities, ensuring their safety and well-being. This practice is particularly crucial in detox facilities and situations where a patient may pose a risk to themselves. Rounds enable close monitoring at short intervals. Outpatient facilities generally do not use rounds since patients do not stay overnight.

Required Permissions: Super admins and records admins have full control over rounds permissions. Users with the Manage Rounds role can log rounds, users with the Review Rounds role can sign off on completed rounds logs, and users with the Manage Templates role can create and customize round templates. Click here to learn more about rounds user permissions. 

Best Practice Workflow Video

Best Practice Workflow

Let's review Kipu EMR's best practice workflows to complete patients rounds and observations checks. 

1. The first step is to enroll the patient in a round interval either during the admission process or when they need closer monitoring. For detailed instructions on the round assignment process, click here.
2. Then, a tech or nurse walks around the facility to complete rounds at each designated interval, entering patient activity, locations, observations, and additional information, such as integrated assessments for vitals, glucose levels, etc., as needed. Check out this article for a step-by-step walkthrough.
• Best Practice: Document rounds in real time using a tablet to eliminate paper documentation, reduce data entry time, and minimize the risk of exposing PHI. Add notes in round interval observations as needed, but if a note requires further action, add a flag or an individual progress note to the patient’s chart to alert providers. These options improve visibility and ensure that providers receive necessary alerts despite the high volume of round entries.
3. After fully documenting a round interval, a shift manager, lead, or program director must provide a review signature. Therapists and healthcare providers should review rounds documentation to assess a patient’s behavior and well-being outside therapy sessions, helping to inform their approach and daily patient evaluations.
   

   Best Practice: Consistently document rounds in a timely manner, adjusting intervals based on the level of care. Some facilities conduct rounds every 15 minutes for medical detox or high-risk patients and every 30 or 60 minutes for lower levels of care.

4. If a round interval is missed, document it as incomplete with the activity corrective action completed. This allows the reviewer to complete the round and ensures accountability.
5. When a patient requires a longer or shorter observation interval, click on the Drop button to remove it from their current round interval (e.g., 15 minutes).
6. After, click +Assign Round and select the new round interval.