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Hospitalist Admission and Rounding Pocket Guide

Orders, Daily Rounds, Handoffs, and Discharge Decisions for the Inpatient Medicine Team

53 quick-reference tables from the back of the book. Tick the ones you want, print, cut along the dashed lines, and slip them into a badge holder or phone case.

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Inpatient vs. observation, traditional Medicare

Table A.1

Feature	Inpatient	Observation
Billed as	Part A inpatient	Outpatient, Part B
Expected need	Care across two midnights	Decision within about 24 to 48 hours
Counts toward SNF three-day rule	Yes	No
Required notice	Admission paperwork	MOON if over 24 hours

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NEWS2 response bands

Table A.2

NEWS2 result	Suggested response
0 to 4	Routine monitoring
Any single parameter scoring 3	Urgent clinician review
5 to 6	Urgent clinician response
7 or more	Emergency response, consider ICU

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SNF three-day qualifying stay rule

Table A.3

Item	Rule
Qualifying stay	3 consecutive inpatient days
Admission day	Counts
Discharge day	Does not count
ED and observation time	Does not count
Start SNF care within	30 days of discharge

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AUDIT-C positive screen thresholds

Table A.4

AUDIT-C	Positive screen
Men	4 or more
Women	3 or more
Range	0 to 12

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Vital sign values that need a second look

Table A.5

Vital sign	Worth a second look
Systolic pressure	Below 90, or 40 or more below baseline
Heart rate	Above 120 or below 45
Respiratory rate	22 or more, or below 10
Oxygen saturation	Below 92 percent on room air
Temperature	38.3 C (101 F) or more, or below 36 C (96.8 F)

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Confusion Assessment Method features

Table A.6

CAM feature	Question
1. Acute onset, fluctuating course	Is there a change from baseline?
2. Inattention	Can they count back from 20 or name the months backward?
3. Disorganized thinking	Is conversation rambling or illogical?
4. Altered consciousness	Is the patient drowsy or hyperalert?

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Typical notify-physician parameters

Table A.7

Parameter	Typical call threshold
Systolic pressure	Below 90 or above 180
Heart rate	Below 50 or above 120
Respiratory rate	Below 10 or above 24
Oxygen saturation	Below 90 percent
Temperature	38.3 C (101 F) or more
Urine output	Below 0.5 mL/kg/hour for 6 hours
Blood glucose	Below 70 or above 300 mg/dL

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Home medications commonly held on admission

Table A.8

Medication	Reason to hold
ACE inhibitor or ARB	AKI, hypotension, sepsis, hyperkalemia
Diuretics	Volume depletion, AKI
Metformin	AKI, contrast, unstable illness
SGLT2 inhibitor	Acute illness, NPO, risk of ketoacidosis
NSAIDs	AKI, bleeding, heart failure
Sulfonylureas	NPO or poor intake, risk of hypoglycemia
DOAC or warfarin	Procedure or bleeding, per plan

Hospitalist Admission and Rounding Pocket Guide. Table A.8. Check local policy before acting.

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Drugs that need renal review

Table A.9

Drug	Concern in reduced kidney function
Enoxaparin	Accumulates and increases bleeding risk
Gabapentin and pregabalin	Sedation, myoclonus, falls
Cefepime	Encephalopathy and seizures
Morphine	Active metabolite accumulates
Baclofen	Encephalopathy
Metformin	Lactic acidosis
NSAIDs	Further kidney injury

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Beers Criteria quick check

Table A.10

Drug class	Why it is a concern
Benzodiazepines	Delirium, falls, fractures
First-generation antihistamines	Anticholinergic effects and confusion
Sulfonylureas (glyburide, glimepiride)	Prolonged hypoglycemia
Sliding-scale insulin alone	Hypoglycemia and hyperglycemia without a basal plan
Long-term PPI use without an indication	C. difficile, fractures
Antipsychotics for behavioral symptoms of dementia	Stroke and mortality

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Common look-alike sound-alike drug pairs

Table A.11

Pair	Distinguish by
hydralazine and hydroxyzine	Indication: blood pressure versus itching or anxiety
clonidine and clonazepam	Indication: blood pressure versus seizure or anxiety
metoprolol tartrate and succinate	Immediate versus extended release
insulin products	Name, concentration, and units

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Critical care time codes (CPT)

Table A.12

Code	Time
99291	First 30 to 74 minutes
99292	Each additional 30 minutes

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Antimicrobial timing in sepsis (SSC 2026)

Table A.13

Situation	Antimicrobial timing
Septic shock, possible or likely	Immediately, within 1 hour
Probable or definite sepsis, no shock	Immediately, within 1 hour
Possible sepsis, no shock	Within 3 hours if infection still likely
Low likelihood of infection, no shock	May defer with close monitoring

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Example empiric antibiotics by source

Table A.14

Source	Example empiric regimen
Community pneumonia	Ceftriaxone plus azithromycin or doxycycline
Urinary tract	Ceftriaxone, or cefepime with risk factors
Intra-abdominal	Ceftriaxone plus metronidazole, or piperacillin-tazobactam
Skin, uncomplicated	Cefazolin or ceftriaxone, add MRSA coverage if risk
Necrotizing soft tissue	Vancomycin, piperacillin-tazobactam, and clindamycin
Hospital-onset, unknown source	Vancomycin plus cefepime or piperacillin-tazobactam

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Vasopressor sequence in septic shock

Table A.15

Step	Agent
First	Norepinephrine
Second	Vasopressin added to norepinephrine
Third	Epinephrine added
Not suggested	Terlipressin

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Shock types by hemodynamic pattern

Table A.16

Type	Cardiac output	Systemic resistance	Filling pressure
Hypovolemic	Low	High	Low
Cardiogenic	Low	High	High
Obstructive	Low	High	Variable
Distributive (septic)	High or normal	Low	Low or normal

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Example rapid response triggers

Table A.17

Trigger	Example threshold
Systolic pressure	Below 90
Heart rate	Above 130 or below 40
Respiratory rate	Above 28 or below 8
Oxygen saturation	Below 90 percent on oxygen
Mental status	Acute change, seizure
Other	Acute bleeding, chest pain, staff worry

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HEART score risk bands

Table A.18

Total	Risk	Approximate 6-week major event rate
0 to 3	Low	About 2 percent
4 to 6	Moderate	About 12 to 16 percent
7 to 10	High	About 50 percent or more

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CHA2DS2-VASc score

Table A.19

Factor	Points
Heart failure	1
Hypertension	1
Age 75 or older	2
Diabetes	1
Prior stroke, TIA, or thromboembolism	2
Vascular disease	1
Age 65 to 74	1
Female sex	1

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CURB-65 score

Table A.20

CURB-65 item	Point
Confusion	1
BUN above 19 mg/dL	1
Respiratory rate 30 or more	1
Systolic below 90 or diastolic 60 or below	1
Age 65 or older	1
Total 0 to 1 low risk; 2 consider admission; 3 or more severe	0 to 5

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CAP antibiotic duration

Table A.21

Pneumonia type	Suggested duration (2025 ATS)
Nonsevere, clinically stable	3 to 5 days
Severe CAP	At least 5 days
Necrotizing, empyema, resistant organism	Longer, individualized

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Oxygen saturation targets

Table A.22

Patient	Target saturation
Most acutely ill adults	92 to 96 percent
COPD or hypercapnia risk	88 to 92 percent
Carbon monoxide poisoning	Highest possible; use 100 percent oxygen

Hospitalist Admission and Rounding Pocket Guide. Table A.22. Check local policy before acting.

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PEN-FAST penicillin allergy score

Table A.23

PEN-FAST item	Points
Reaction within the last 5 years	2
Anaphylaxis, angioedema, or severe skin reaction	2
Treatment was required	1
Score 0 very low risk; 1 to 2 low; 3 moderate; 4 to 5 high	Total

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Glasgow-Blatchford score components

Table A.24

Glasgow-Blatchford item	Points
BUN 18.2 to 22.3 mg/dL (rising to 70 or more)	2 to 6
Hemoglobin below threshold, by sex	1 to 6
Systolic BP below 110 (to under 90)	1 to 3
Heart rate 100 or more	1
Melena, syncope, hepatic disease, or heart failure	1 to 2 each

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Liver test patterns

Table A.25

Pattern	Think of
AST and ALT over 1,000	Ischemia, acetaminophen, viral hepatitis, autoimmune
AST over ALT 2:1	Alcohol-associated disease
Alkaline phosphatase and bilirubin up	Biliary obstruction, cholestasis, infiltration
Isolated bilirubin up	Hemolysis, Gilbert syndrome, sepsis

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Prerenal azotemia vs. acute tubular necrosis

Table A.26

Test	Prerenal	Acute tubular necrosis
Urine sodium (mEq/L)	Below 20	Above 40
FENa	Below 1%	Above 2%
FEUrea	Below 35%	Above 50%
Urine sediment	Bland or hyaline casts	Muddy brown granular casts
Response to fluids	Creatinine falls in 24 to 72 hours	No change

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Common renal dose adjustments

Table A.27

Drug	Adjustment
Enoxaparin	1 mg/kg once daily if CrCl below 30
Cefepime	Reduce dose to avoid neurotoxicity
Gabapentin	Lower dose and longer interval
Metformin	Stop if eGFR below 30
Trimethoprim-sulfamethoxazole	Halve dose if CrCl 15 to 30

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Expected compensation in acid-base disorders

Table A.28

Disorder	Expected compensation
Metabolic acidosis	PaCO2 = 1.5 x HCO3 + 8 (plus or minus 2)
Metabolic alkalosis	PaCO2 rises about 0.7 per 1 rise in HCO3
Acute respiratory acidosis	HCO3 rises 1 per 10 rise in PaCO2
Chronic respiratory acidosis	HCO3 rises 3.5 per 10 rise in PaCO2

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Glucose monitoring schedule

Table A.29

Setting	Check glucose
Eating	Before meals and at bedtime
NPO or continuous tube feeds	Every 4 to 6 hours
IV insulin	Every 1 to 2 hours
Steroid therapy	Before meals and at bedtime, with a 2 a.m. check in selected cases

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Home diabetes drugs on admission

Table A.30

Drug	Inpatient plan
Metformin	Hold for AKI, contrast, sepsis, or poor intake
SGLT2 inhibitor	Hold; risk of ketoacidosis when acutely ill or NPO
GLP-1 agonist	Hold if vomiting, ileus, or pancreatitis; consider continuing if eating
Sulfonylurea	Hold; hypoglycemia risk
DPP-4 inhibitor	May continue; linagliptin needs no renal adjustment
Insulin	Continue basal at a reduced dose and add correction

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Stress dosing with hydrocortisone

Table A.31

Stress	Hydrocortisone
Minor illness, fever	Double or triple the usual dose for 2 to 3 days
Moderate stress or surgery	50 mg IV, then 25 mg every 8 hours
Severe illness, shock, major surgery	100 mg IV, then 50 mg every 6 to 8 hours

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Choosing an anticoagulant

Table A.32

Drug	Typical use	Kidney note
Unfractionated heparin	ACS, high bleeding risk, unstable PE, severe kidney disease	Safe in kidney failure
Enoxaparin	VTE treatment 1 mg/kg every 12 h	Reduce to daily if CrCl below 30
Apixaban	VTE, atrial fibrillation	Least renal clearance of DOACs
Rivaroxaban	VTE, atrial fibrillation	Take with food; avoid if CrCl below 15
Warfarin	Mechanical valves, antiphospholipid syndrome, severe kidney disease	Needs INR monitoring

Hospitalist Admission and Rounding Pocket Guide. Table A.32. Check local policy before acting.

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Anticoagulant reversal

Table A.33

Agent	Reversal
Warfarin	4-factor PCC 25 to 50 units/kg plus vitamin K 10 mg IV
Apixaban, rivaroxaban	Andexanet alfa or 4-factor PCC 2,000 units (50 units/kg)
Dabigatran	Idarucizumab 5 g IV
Unfractionated heparin	Protamine 1 mg per 100 units given in the last 2 to 3 hours
Enoxaparin	Protamine 1 mg per 1 mg given within 8 hours (partial reversal)

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Duration of VTE treatment

Table A.34

Situation	Duration
Major transient risk (surgery, trauma, immobility)	3 months
Minor or non-surgical transient risk	3 months, consider extended
Unprovoked or persistent risk	Extended therapy, reduced-dose apixaban or rivaroxaban after 6 months
Active cancer	Extended while cancer is active; DOAC or LMWH
Antiphospholipid syndrome	Warfarin, indefinite

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Transfusion thresholds

Table A.35

Product	Threshold
Red cells, stable adult	Hemoglobin below 7 g/dL
Red cells, cardiovascular disease or orthopedic surgery	Below 8 g/dL
Acute coronary syndrome	Individualize; MINT trial favored a liberal strategy in myocardial infarction with anemia
Platelets, no bleeding	Below 10,000/mm3
Platelets, central line placement or procedures	Below 20,000 to 50,000/mm3
Plasma	Active bleeding with coagulopathy, not to correct a mild INR

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Oncologic emergencies at a glance

Table A.36

Emergency	Clue	First action
Spinal cord compression	Back pain with weakness	Dexamethasone, MRI
Superior vena cava syndrome	Facial swelling, dyspnea	CT, oncology, airway watch
Tumor lysis syndrome	High K, phosphate, uric acid after treatment	Fluids, rasburicase
Hypercalcemia	Confusion, polyuria	Saline, zoledronic acid
Febrile neutropenia	Fever, low ANC	Antibiotics in 60 minutes
Malignant effusion or tamponade	Dyspnea, hypotension	Ultrasound, drainage

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Checkpoint inhibitor toxicities

Table A.37

Organ	Typical sign	First step
Colon	Diarrhea, abdominal pain	Stool studies, steroids, infliximab if refractory
Lung	Cough, hypoxia, ground-glass change	CT, bronchoscopy, steroids
Liver	Raised ALT and AST	Exclude other causes, steroids
Endocrine	Thyroid, pituitary, adrenal, diabetes	Hormone replacement
Heart	Chest pain, arrhythmia, troponin rise	ECG, troponin, high-dose steroids, cardiology

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Symptom control at the end of life

Table A.38

Symptom	Treatment
Pain or dyspnea	Opioid such as morphine 2 to 5 mg IV, or hydromorphone, titrated; infusion for continuous need
Secretions	Glycopyrrolate 0.2 mg or scopolamine; reposition
Agitation or delirium	Haloperidol 0.5 to 2 mg; midazolam for refractory distress
Nausea	Haloperidol or ondansetron
Fever	Acetaminophen rectally

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Approximate equianalgesic doses

Table A.39

Drug	Oral (mg)	IV (mg)
Morphine	30	10
Hydromorphone	7.5	1.5
Oxycodone	20	Not available IV
Fentanyl	Not applicable	0.1

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Revised Cardiac Risk Index

Table A.40

RCRI factor	Points
High-risk surgery	1
Ischemic heart disease	1
Heart failure	1
Cerebrovascular disease	1
Insulin-treated diabetes	1
Creatinine above 2 mg/dL	1

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Preoperative testing guide

Table A.41

Test	Order when
ECG	Known heart disease, arrhythmia, or elevated-risk surgery
Hemoglobin	Major surgery with expected blood loss, anemia symptoms
Creatinine	Kidney disease, diabetes, heart failure, nephrotoxins
Coagulation tests	Bleeding history or anticoagulant use
Chest film	New or unexplained cardiopulmonary symptoms
Pregnancy test	Women of childbearing potential

Hospitalist Admission and Rounding Pocket Guide. Table A.41. Check local policy before acting.

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Home medications before surgery

Table A.42

Drug	Plan
Beta-blocker, statin, antiepileptic, inhaler	Continue
ACE inhibitor or ARB	Often held 24 hours before surgery to avoid hypotension; follow local protocol
Diuretic	Hold on the morning of surgery unless needed for heart failure
SGLT2 inhibitor	Hold 3 to 4 days
Metformin	Hold on the day of surgery
Aspirin	Continue for secondary prevention
Herbal supplements	Stop 1 to 2 weeks before

Hospitalist Admission and Rounding Pocket Guide. Table A.42. Check local policy before acting.

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Drugs to avoid in older adults (Beers examples)

Table A.43

Drug or class	Concern
Diphenhydramine, hydroxyzine	Anticholinergic: delirium, retention
Benzodiazepines, Z-drugs	Falls, delirium, fractures
Glyburide	Prolonged hypoglycemia
NSAIDs	Kidney injury, GI bleeding, heart failure
Proton pump inhibitors, long-term	C. difficile, fractures; review need
Antipsychotics in dementia	Mortality and stroke

Hospitalist Admission and Rounding Pocket Guide. Table A.43. Check local policy before acting.

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Choosing IV access

Table A.44

Need	Access
Fluids, most antibiotics, up to about 6 days	Peripheral IV
Midline	1 to 4 weeks of non-irritant therapy
Vasopressors, TPN, irritants, or prolonged antibiotics	Central line or PICC
Kidney disease stage 3b to 5	Avoid PICC; preserve veins for fistula

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Common deficiencies and treatment

Table A.45

Deficiency	Treatment
Thiamine	IV 100 to 500 mg before glucose
B12	1,000 mcg IM or oral daily
Folate	1 to 5 mg daily, after excluding B12 deficiency
Vitamin D	Replace per level; check calcium
Iron	Oral every other day, or IV if intolerant

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Consult urgency

Table A.46

Level	Meaning	Examples
Emergent	Immediate, by phone	STEMI, stroke, cord compression, unstable GI bleed
Urgent	Within hours	Cholangitis, septic joint, new heart block
Routine	Within 24 hours	Anemia workup, new murmur, diabetes education
Elective	Can be done as outpatient	Screening tests, non-urgent referral

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Critical values and first steps

Table A.47

Value	First step
Potassium 6.0 or higher	ECG, repeat, treat if ECG changes
Sodium below 120	Symptoms, urine studies, careful correction
Glucose below 54	Treat now
Hemoglobin below 7	Look for bleeding, type and screen
Troponin positive	ECG, repeat in 3 hours, evaluate
Lactate above 4	Assess for sepsis or shock

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Four abilities of decision-making capacity

Table A.48

Ability	Ask
Understand	Tell me in your own words what the doctors told you.
Appreciate	What do you think is wrong with you, and how would the treatment help?
Reason	How did you decide? What are the pros and cons?
Express a choice	What have you decided?

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Advance care planning documents

Table A.49

Document	Who	Purpose
Advance directive or living will	Any adult	States wishes and names an agent
Health care proxy	Any adult	Names the decision-maker
POLST	Seriously ill or frail patients, with a clinician	Medical orders for resuscitation and treatment

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Choosing the next setting

Table A.50

Setting	Fits a patient who
Home with services	Can manage with supports
Skilled nursing facility	Needs daily skilled nursing or therapy, but cannot tolerate intensive therapy
Inpatient rehabilitation	Needs and tolerates about 3 hours of therapy daily, with a goal of returning home
Long-term acute care	Has complex medical needs, such as prolonged ventilator weaning
Hospice	Has a prognosis of 6 months or less and chooses comfort

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LACE index

Table A.51

LACE component	What it measures
Length of stay	Days in hospital
Acuity	Emergency admission
Comorbidity	Charlson index
ED visits	Visits in the previous 6 months

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Specificity in diagnosis documentation

Table A.52

Less specific	More specific
Heart failure	Acute on chronic systolic heart failure
Kidney injury	AKI due to acute tubular necrosis
Pneumonia	Aspiration pneumonia with acute hypoxic respiratory failure
Anemia	Acute blood loss anemia
Sepsis	Sepsis due to E. coli UTI, with organ dysfunction named

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Subsequent inpatient visit levels

Table A.53

Level	Typical medical decision-making
Low	Stable problem, minimal data, low risk
Moderate	Multiple problems or one acute illness, some data, prescription drug management
High	Threat to life or bodily function, extensive data, decision about escalation or DNR

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Educational study aid, not clinical advice. Always follow your facility's protocols, the orders of the responsible provider, and current drug labeling. Ranges and doses must be checked against your local references.