The Inpatient Clinical Rotation - What does it look like?

Addison and Juno take a quick break upstairs in between patients.

As a dietetic intern, I’ve been given a lot of choices as to where I can practice my skills, but some things are locked in. Every intern needs rotations in food service, community, and clinical to hit every CRDN necessary for the certification exam. There was no other rotation I looked forward to more than my initial clinical rotation.

I had some experience working in a hospital before beginning my clinical rotation, but I still had no idea what to expect. Working as a nutrition assistant (a half-step down from an NDTR) in a small hospital in the San Francisco Bay area was leagues away from the demands of a major metropolitan hospital. I would have liked to see a guideline or a play-by-play of what an average day looks like for a dietetic intern. 

Here is a day in the life as a dietetic intern at MedStar Washington Hospital Center! 

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The Morning.

0500 - First set of alarms. I set three to make sure I get out of bed to turn them off.

0505-0530 - I do some self-care and prepare coffee. Always coffee. 

I also check the weather to see if I need specific clothing pieces. The office can be anywhere between freezing and warm - layers are your best friend. 

0530-0610 - Iron and don scrubs/professional attire, check my watch, gather my lunch, bags, and *service dog.

*Note: Dog not required for a dietetic internship.

0610-0710 - I hit the road with some early morning tunes to wake up. If I’m already energized, I pop on a nutrition care podcast for the clinical expertise I’m working on that week. 

The Research. 

0730~0900 - I start the day at the hospital with my patient list and breakfast. The number and type of patients increased in intensity over time and were assigned to me in the morning by request.

I read through patient charts, taking notes on their history/physical, physician’s notes, nurse notes, critical updates, consultations, medications (active and discontinued), whether or not they had injuries/edema or difficulties chewing/swallowing (thank you speech-language pathologists!), and marked down their vitals to have the most updated information. All the while I’m fueling my day with a chocolate chip and protein-powder-loaded oatmeal. 

The amount of mental energy expended in the clinical rotation is real. Remember to fuel your body and hydrate properly - we cannot survive off of coffee and a piece of toast alone. 

The Assessment. 

0900-1030 - I’m upstairs seeing my assigned patients for the next hour and a half. Sometimes it takes less time, sometimes more, based on the patient’s energy or whether or not I’m providing education. 

A typical nutrition assessment looks like a normal conversation. I review the patient’s notes I’d written down outside the door/unit (just so I know I have the **right person), and then I knock and introduce myself. I tell them that I’m there because I want to check on how they’re eating in the hospital, and this usually opens up the conversation about their appetite, meal history before and after admission, weight history, whether or not they have issues chewing/swallowing, and GI upset. Sometimes, it can be difficult to get all this information - that’s why knowing patient history is great for prompting their memory. After gathering the necessary information, I’ll curtail our meeting with a quick nutrition-focused physical exam and ask follow-up questions. If needed, I may offer some oral supplements (they often need them). Last thing: always summarize the meeting and ask if they need anything before you leave. This is respectful and grants them autonomy where they are otherwise on the hospital’s time. 

**Always always always confirm you have the right person - people get moved around in the hospital all of the time. Confirming a birthdate is standard practice, and sometimes patients have readily available bracelets the nursing staff use for medication administration purposes. Don’t be afraid to ask for this information - by asking, you’re protecting your patients from harm. 

The Chart. 

1030-1130 - The next hour or so is spent in the initial parts of the notes. At my initial clinical rotation, I had to fill out a worksheet that compiled most of the objective information gathered (ex. current body weight, usual body weight, height, kilocalorie per kilogram range, protein needs, etc) as well as some of the subjective data like the NFPE. Filling out this template auto-populates into the chart note. 

My preceptors’ roles in this process were to evaluate my worksheet and evaluate the accuracy of my PES statements, interventions, and malnutrition diagnoses. They would ask questions based on clinical judgment about protein/calorie needs or appropriate usual weight based on past medical history. Once the worksheet met their expectations, they’d sign off, and I’d begin my charting. 

My early process for enteral and parenteral nutrition calculations. This example is derived from a case study.

I always began my note the same way: “X-year-old w ***PMH of [current active diseases], PSH of [recent and relevant surgical history], presents to [the hospital] with complaints of [symptoms].” It is important to summarize the patient's history in this part of the note. When other practitioners review your subjective visit with them, they want to have a concise yet collective view of the patient. I document my interaction with the patient, making sure to hit on important details relevant to their disease state and acute care clinical nutrition (appetite, weight history, nausea/vomiting/diarrhea/constipation, etc). 

Throughout the charting, I refer to the nutrition care manual, Krause, my copy of the NFPE guide, and other resources to ensure I understand the full picture myself. Knowing that EGD is esophagogastroduodenoscopy (a procedure where a scope is snaked through the upper GI to look for lesions or other issues) or the difference between HFrEF and HFpEF is “heart failure with [reduced/preserved] ejection fraction” can give me crucial information I’d otherwise miss. Ask your preceptors questions if you cannot find the answers yourself. You’re an intern - it’s okay not to know every piece of MNT yet, but make sure you look into the questions yourself first. 

*** I forgot to mention that when I was doing my research earlier in the day, I was using a particular tool in this hospital’s system to “bookmark” important information. Dates of procedures, nutrition-related symptoms, occurrences of rapid response or critical states, whether a patient was transferred to the ICU, etc. Some medical records are extensive and go back several months if the patient has been there for a long period or has been readmitted after a long stay. Find the best way for you so you don’t have to sift through it a second time. 

The Afternoon.

Addison's service dog Juno snoozes in the grass during their lunch break.

1230-1300 - This is the usual period I take for my lunch. I liked to take the time to go outside, let my dog run and stretch her legs after being curled up under my chair, and get some sun on my cheeks. The dietitian’s office is in the basement without windows, so it was nice to remind myself of the sun every now and then. Even if you’re not hungry or swamped with work, take this break to refresh your mind and take care of yourself. 

1300-1600 - The remainder of the day typically repeats the morning routine. I finish my patient notes and review them with my preceptors, asking questions as necessary. If I complete my caseload in enough time, I'll receive one or two extra cases to help my preceptors get ahead for the next day. I may go back upstairs to follow up with a physician or a nurse. Sometimes I check in with a patient once more to get more information or drop off requested education. It’s highly variable at this point in the day. Time management is essential to making sure the day goes smoothly. Pay attention to your preceptor’s schedule and you’ll become a well-oiled machine. 

The Evening.

****1630-1800 - I commute home and take care of my crucial tasks. I do grocery shopping, brief exercise, and other chores I need to complete around the home. Life continues regardless of our internship, and we need to account for the activities of daily living as much as possible so as not to fall behind. This is also a necessary time to make sure my dog’s needs are met for the next day of work. 

****Note: not everyone’s commute is this long, but mine is. You’ll likely have more time for afternoon activities if you live closer to your internship site. 

1800-2100 - This is homework time. I usually multitask at this point and use a screen reader to auto-read through research papers or homework assignments while I’m eating. There may be another cup of coffee involved (do not do this if you’re caffeine-sensitive or having trouble with sleep!). 

2100 - At this time, I’m preparing for the next day. Making my lunch, preparing another protein-packed oatmeal with way too much chocolate and almonds, and laying out my scrubs/slacks/jackets. Whatever I can take care of at night, I don’t have to do in the morning. 

2230+ - Somewhere late at night, I’m getting ready for sleep. As future healthcare professionals, we know the value of quality sleep and the effect it has on the body when we don’t get enough. Make sure you value your sleep and schedule it into your days if needed. Your mind and your performance will thank you for it.

The End. 

However your clinical rotation looks, know that there are helpful tools out there that can help you succeed. Familiarizing yourself with your strengths and weaknesses going into clinical practice will help address these challenges early. Keep a journal of disease states you’re unfamiliar with. Build a spreadsheet with medications to act as a quick reference guide. Set timers to help keep you on task. Refresh on metabolic pathways if necessary. Always ask questions.

Clinical practice is demanding, but it can be extremely rewarding to help a patient in their time of need. Keep pushing! You can do it!