Morning Routine Map: 5:00–8:00am Playbook for Pre-Rounds and Sign-Out

It’s 4:59 a.m. Your alarm is about to go off for the third time. You’re on inpatient wards as a brand-new intern. Night float is going to sign out in about an hour. And your brain is trying to decide which feels worse: getting out of bed or showing up unprepared to your first real pre-rounding and sign-out as the “doctor.”

Here’s the reality: 5:00–8:00 a.m. will make or break your day. Not in some motivational-poster way. In a very real, “Did you miss that patient’s 3 a.m. rapid response?” way. Or “Why is the attending asking you about the sodium you didn’t check” way.

You need a map. Hour by hour, then minute by minute. At each point, you should know exactly what you’re doing, what you’re checking, and what you can safely ignore.

This is that map.

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5:00–5:30 a.m. – Wake-Up, Non-Negotiables, and Mental Boot-Up

At this point you should be: out of bed and doing the same exact thing you do every inpatient morning. Consistency saves you here.

5:00–5:05 – Zero-thinking wake-up

Your first mistake is trying to “decide” to get up.

Set things up the night before so 5:00–5:05 is pure autopilot:

• Phone/alarm across the room.
• Scrubs, socks, and shoes laid out.
• Badge, keys, wallet all in one visible spot.
• Bag already packed with:
  • Laptop/iPad
  • Charger
  • Stethoscope
  • Pen + backup pen
  • Small notebook
  • Snacks

At 5:00, you should be:

1. Up, not scrolling.
2. Bathroom.
3. Contacts/glasses in, face washed, teeth brushed.

No decisions. No “maybe I’ll sit down for a second.” You don’t sit until you’re at the hospital.

5:05–5:15 – Fast body maintenance

You’re not doing a 30-minute skincare routine here. You’re doing “don’t feel like a corpse” prep.

Bare minimum I recommend:

• Drink a full glass of water. You’re mildly dehydrated, whether you feel it or not.
• Caffeine plan:
  • If you have a long commute: make coffee/tea to go.
  • If you’re close to the hospital: wait and grab it there.
• Quick stretch (1–2 minutes): neck, shoulders, lower back. You will stand a lot today; your body will remember this more than another 5 minutes in bed.

At this point you should be dressed for work, with your bag by the door.

5:15–5:30 – Commute: mental pre-round

This commute is not Netflix time. It’s mental boot camp.

If you’re driving:

• No reading, obviously. Use audio:
  • Brief podcast on hospital medicine, critical care, or your specialty.
  • Or silence. Honestly, some days silence is better.

If you’re on public transit:

• Open your EHR app (if allowed) to:
  • Skim overnight vitals for your highest-risk patients.
  • Check new labs for anyone you were worried about.
  • Look for new admissions assigned to your team overnight.

Your mental checklist on the way in:

• Top 3 sickest patients on your list:
  • What was the plan last night?
  • Any expected changes? (diuresis, transfusion, antibiotics)
• Any time-sensitive stuff this morning:
  • Planned procedures (OR, IR, colonoscopy)
  • Time-sensitive meds/monitoring (heparin drips, pressors, insulin drips)

You’re not managing care from the bus. You’re just priming your brain so sign-out makes sense, fast.

Time Allocation: 5:00–5:30 a.m.

Category	Value
Personal care	35
Commute	45
Mental prep	20

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5:30–6:00 a.m. – Arrive, Set Up, and Quick Chart Triage

At this point you should be: in the hospital, logged in, and looking at data, not wandering around looking for a pen.

5:30–5:35 – Physical setup

Walk in like you’ve done this a hundred times:

• Drop your bag in the team room/locker.
• Badge on if it isn’t already.
• Grab:
  • Rounding list (printed if your team does that)
  • Sign-out sheet template or notebook
  • One black pen, one colored pen or highlighter

Open your workstation and launch:

• EHR (main)
• PACS/imaging viewer (if separate)
• Any pager or messaging system on your computer

5:35–5:45 – Generate or update your patient list

Your list is your life. If the list is a mess, your morning will be a mess.

At this point you should:

1. Pull the most current patient census for your team.
2. Compare to yesterday’s list:
   • New patients? Mark them clearly.
   • Discharges? Remove them.
   • Transfers (ICU–>floor, floor–>ICU)? Flag those.
3. Make sure for each patient you have:
   • Room number
   • Attending
   • Code status
   • Active problems (1–3 words each, no novels)

This is where you catch early:

• “Wait, who is this new admission?”
• “Why is this patient listed as ‘ICU’ but still on our list?”

5:45–6:00 – Overnight data scan: labs, vitals, events

Before you talk to night float, you should already have a rough idea of what happened.

Go patient by patient, but prioritize sickest first:

For each:

• Vitals:
  • Any hypotension, tachycardia, new fever overnight?
  • O2 requirements changed?
• I/Os:
  • Massive positive or negative balance?
  • Did they pee? (Especially if AKI or post-op)
• Labs:
  • Morning BMP and CBC if already drawn:
    • Potassium
    • Creatinine
    • Hemoglobin
    • WBC
  • Any notable trends:
    • Sodium creeping up or down
    • Worsening renal function
• Events:
  • Any rapid response, codes, or significant nursing calls?
  • New imaging done overnight?

You’re not solving problems now. Just flagging:

• “Needs K repletion”
• “Worse creatinine”
• “New fever, cultures last night”

Mark these directly on your list.

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6:00–6:30 a.m. – Night Float Sign-Out: What To Ask and What To Ignore

At this point you should be: physically at sign-out, with your list printed or on screen, pen in hand, ready to write only what you’ll actually use.

6:00–6:05 – Get there on time and ready

You walk in before or exactly at the sign-out time. Not two minutes after, breathless, apologizing.

Have:

• Your patient list
• Sign-out area clearly separated:
  • “To know” vs “To do”
• A simple format per patient:
  • Yesterday’s plan
  • Overnight events
  • Pending items

6:05–6:25 – Structured, efficient sign-out

You’re not a court stenographer. Don’t write every word they say.

For each patient, at this point you should capture:

1. Big overnight changes
   • “Hypotensive at 3 a.m., got 1L bolus, now stable”
   • “New chest pain, EKG and trops sent, normal”
2. Outstanding studies or labs
   • “Blood cultures pending from yesterday”
   • “CT abdomen pending – ordered overnight”
3. Time-sensitive tasks for the morning
   • “Follow up K+ and replete before rounds”
   • “Check post-transfusion CBC at 8 a.m.”
   • “Touch base with family – they’ll be here ~9 a.m.”

What you can safely not write word-for-word:

• Re-hashing the admission story you already know
• Every normal vital overnight
• Non-actionable gripes (“Pt pulled off monitor again” unless it changes your plan)

Push back if sign-out is vague. Ask direct questions:

• “When was the last set of vitals?”
• “Did anyone actually lay eyes on him after that hypotension?”
• “Is the attending aware of this new issue?”

Your goal by 6:25:

• You know which 3–5 patients need your eyeballs first
• You know which labs or imaging you absolutely need to check again before rounds
• You don’t have 17 pointless notes cluttering your brain

6:25–6:30 – Triage your list post sign-out

Right after sign-out, do not chat, scroll, or wander. Take 5 minutes and rewrite your top priorities.

Make a simple 3-column system on your list:

Patient Priority	Must Do Before Rounds	Can Do After Rounds
High	See in person	Call family
Medium	Check labs	Reconcile meds
Low	Skim vitals	Update note details

By 6:30, you should know:

• Which patients you’ll see in person before 7:30
• Which charts you’ll review only (if that’s acceptable on your service)
• What absolutely cannot be forgotten

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6:30–7:30 a.m. – Pre-Rounds: Bedside Plus Chart in a Tight Window

This hour is where interns drown. Too slow and you’ll miss patients. Too superficial and your attending will expose it in 10 seconds.

You’re going to rotate between:

• Targeted chart review
• Short bedside checks
• Quick task ordering (when obvious)

6:30–6:40 – Start with your sickest patient

At this point you should be at the bedside of the patient most likely to crash or be discussed first.

Before you walk in:

• Re-skim:
  • Latest vitals
  • Overnight MAR (what meds were actually given?)
  • Any new labs you flagged

In the room, your pre-round script is tight:

1. Introduce yourself if they’re new to you.
2. 3–4 focused questions:
   • “How are you feeling compared to yesterday?”
   • “Any chest pain, trouble breathing, dizziness?”
   • “Any new pain anywhere?”
   • “Eating, drinking, peeing, pooping okay?”
3. Quick focused exam based on their problem:
   • CHF: JVP, lungs, edema, weight
   • PNA: work of breathing, O2 sat, cough
   • GI bleed: abdominal exam, mental status, any new blood
4. Double-check:
   • Lines/tubes/drains
   • Foley still in? (If yes, does it still need to be?)
   • Central lines needing removal?

Before you leave the room:

• Write one or two micro notes on your list:
  • “Less SOB, still 2+ edema, on 3L O2”
  • “Pain better, tolerating diet”

6:40–7:10 – Systematic pre-round on remaining patients

You’re not doing full H&Ps. You’re doing targeted updates.

Approach:

• High and medium-priority patients: in-person.
• Low-priority, stable patients:
  • On some services, a robust chart review + nursing check may be enough some mornings. Ask your senior what’s acceptable. Don’t guess.

Per patient, aim for 3–5 minutes:

1. Chart snapshot (30–60 seconds):
   • Vitals trends (last 24 hours vs last 8 hours)
   • I/Os
   • New labs
   • MAR: Did they get their meds? Any PRNs used (pain, nausea)?
2. Bedside (2–3 minutes):
   • One-line check-in: “How are you today compared to yesterday?”
   • Focused symptom questions tied to their main issues
   • Targeted exam only
3. Quick orders if obvious (optional but efficient):
   • If potassium is 3.1 and you already know the protocol, just order the repletion now.
   • If patient needs PT/OT and it’s clearly overdue, place the consult.

You’re not writing full notes yet. You’re building:

• Today’s “one-liner” update in your head
• 2–3 key data points and decisions per patient

Pre-Rounds Time Per Patient (Average)

Category	Value
Chart review	2
Bedside check	3
Orders	1

7:10–7:25 – Quick documentation seeds and orders

By now, you should have seen the key patients. Use this pocket of time well.

At this point you should:

• Enter urgent orders you’ve been holding:
  • Electrolyte repletion
  • Diet changes
  • Imaging that will delay disposition if you wait
• Drop “note skeletons”:
  • Open each patient’s progress note and jot:
    • Updated one-liner
    • Today’s planned problem list headers
  • Save as drafts. Don’t over-write now.

Example for your draft note:

• One-liner: “65M with HFrEF, HTN, admitted with acute decompensated HF, now improving diuresis.”
• Problems:

You’ll fill these in later. The structure saves you time post-rounds.

7:25–7:30 – Final pre-round huddle with yourself

Last 5 minutes before morning conference or rounds start:

• Re-scan your list:
  • Any labs still pending that will change management?
  • Any task you promised to do “right after sign-out” that you haven’t touched?
• Star or box:
  • The 1–2 main points you want to say for each patient on rounds:
    • “Net negative 1.5L, creatinine stable, plan to continue diuresis.”
    • “Still febrile overnight, cultures pending, broadened abx.”

You want to walk into rounds with a headline for each patient, not a random pile of facts.

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7:30–8:00 a.m. – Handoff to Day, Conference, or Team Rounds

Different programs run this half-hour differently. Some:

• Have morning report at 7:30.
• Start attending rounds at 7:45.
• Or have a brief 7:30 “team pre-round huddle.”

Whichever flavor you have, here’s what you should be doing at this point.

If you have a 7:30 conference

Your priority: Don’t show up late, and don’t sit there panicking about your list.

Before you walk in:

• Make sure:
  • All urgent labs are ordered.
  • Any acutely unstable patient has been seen in person.
• Have your list with:
  • One-line update per patient.
  • Star next to anyone you’re really worried about.

During conference:

• You’re expected to be present, but if you get a page about one of your patients, you answer it.
• Quick mental game: For each patient, try to state in your head:
  • “Today I care most about X” (e.g. “diuresis goal,” “controlling pain,” “weaning O2”)

If you go straight to team rounds

Here’s where good pre-rounding pays off.

For each patient you present between 7:30–8:00, you should be able to say:

• One-liner with today’s frame, not just admission story.
• Overnight:
  • “No acute events” or
  • “Had X, we did Y, now Z.”
• Key objective data:
  • Vitals trend (don’t read every number)
  • One-line labs: “Cr slightly up from 1.2 to 1.5,” or “Hgb stable around 8.5”
• Today’s plan in 2–3 bullets:
  • “Continue IV diuresis, repeat BMP at 2 p.m., if Cr stable and net -1L, consider transitioning to oral tomorrow.”

You should not be:

• Flipping through the chart while talking.
• Seeing new problems for the first time in front of the attending.
• Surprised by a basic lab you could’ve checked at 6:00 a.m.

If you’re handing off to another day team (e.g., you’re night float ending at 8:00)

Different angle, same discipline.

Your 7:30–8:00 should be:

• Tight, structured sign-out back to day intern:
  • Sickest first
  • New admissions with clear one-liners and pending work-up
  • Any patient you were worried about overnight, whether or not they “looked okay” at 5 a.m.
• No rambling stories. No mysteries.
• Clear red flags:
  • “If BP trends down again, please re-evaluate early.”
  • “If CT shows X, plan is Y – attending aware.”

5:00–8:00 a.m. Morning Routine Timeline

Period	Event
5	00-5
5	30-6
6	00-6
6	30-7
7	30-8

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Putting It All Together: Your 5:00–8:00 a.m. Playbook

Strip away the noise and your morning comes down to three things:

1. 5:00–6:00 a.m.: Get yourself functioning and get your data straight.
2. 6:00–7:30 a.m.: Extract what actually matters from the night and the chart, then lay eyes on the patients who need you most.
3. 7:30–8:00 a.m.: Communicate clearly – in sign-out, in conference, and on rounds – using the prep you already did, not scrambling to catch up.

You’ll tweak this routine for your hospital, your service, and your own brain. But the structure stays the same: wake, orient, receive, verify at the bedside, then present. Every single morning.