Physician Round Tool and Instructions (Word file: 23KB/3 pages)

Physician Round Tool
Check one
New Admission:
Resident Name
Continued Reassessment:
New Onset of Behaviors:
Medication(s) & Dose
(Rationale for starting Medication)
Date Medication Started
Date Prior Reduction
Result of Reduction
Resident specific target behaviors
Any targeted behaviors since admission, readmission or dose reduction? Yes ☐ No
If present, have they: INCREASED / DECREASED / UNCHANGED (please circle one)
Non-pharmacological approaches tried (list):
Were the non-pharmacological approaches effective?
Yes ☐
No ☐
Any functional declines since the medication was started?
If Yes, describe
Yes ☐
No ☐
Any S/S weight loss, dehydration or skin issues?
If Yes, describe
Yes ☐
No ☐
Any nursing or Care Plan Team concerns
Family concerns
BIMS score
PHQ9 score
Any rapid onset of behavior indicating delirium?
Yes ☐
No ☐
Has a medical condition or environmental factors been ruled out (ex: pain, fluid/electrolyte imbalance,
infection, medication side effects or poly pharmacy (any nurse concerns list here for physician, may attach lab
Yes ☐
No ☐
Any lab tests needed?
1. Please review for a trial dose reduction as the need for psychotropic medications if there is
presence/absence of targeted behavior.
2. Please document effectiveness of non-pharmacological interventions and the presence or absence of
medication side effects.
3. Regulations state that dose reduction attempts will be made within the first year, in two separate quarters,
(at least 1 month between attempts), then annually.
Antipsychotics benefit only some residents and are associated with side effects. Often the only way to know if a
medication is of benefit or still needed is to try to taper the dose. If a dose reduction is not indicated for this patient
due to past failed dose reduction attempts within this facility, you must document your rationale on how a dose
reduction would likely impair function or cause psychiatric instability by exacerbating an underlying medical or
psychiatric condition including the targeted reasons for starting and continuing the medication.
Instruction Sheet for use with Physician Round Tools
Nurse to complete sheet prior to physician rounding.
 Copy of resident vital signs for past 30 days or since admission/readmission date
 Any falls and rationale for fall
 Current weight and inform physician of any weight loss or gain
 If diabetic, last AIC and copy of accuchecks
 Any worsening of mental function
 Copy of Consultant Pharmacist recommendations
Have available for physician Antipsychotic medication list from F 329 and indications for use to review with physician if
Round with the physician.
If physician determines a dose reduction, communicate to staff need for observation and documentation of resident’s
mood, behavior and response, i.e., increased alertness, wakefulness, etc.
Follow up when physician’s progress note is available to assure dictation supports a reduction of the medication or to
assure there is clear documentation to support continued use of the medication including targeted behaviors for which
the medication was started.
If physician has not addressed a reduction or does not document rationale for continued use of the medication, review
with medical director, consultant pharmacist and Quality Assurance Committee.
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