Post on 20-Dec-2015
Presenting a Patient - Guidelines and TipsCORE Presentation Adapted by Primary Care Associates
July 5th, 2011
Presenting a Patient – Premises
Purpose: To concisely convey information to another health care provider
Present information needed to develop a basic understanding of the patient’s current state of health
This fundamental skill will be part of your professional communications for the remainder of your career
Just as with documentation, standardized format enhances clarity and minimizes confusion
Presenting a Patient – Premises
The format of a formal Patient Presentation differs according to:
• the service (ambulatory family medicine, surgery, emergency medicine, etc.)
• the setting (hallway, exam room, “rounds discussion” table, etc.)
• the listener (preceptor, resident, department staff, etc.)
TIP: Ask the preceptor/resident about oral case presentation guidelines at the start of the rotation
Presenting a Patient – Basics
Rule of thumb: BE BRIEF
Family history, social history and review of systems are frequently excluded from the case presentation • Especially the “acute problem” presentation (ED, UC, FM)• However, ALL details should be investigated in case they are
significant
Elements of the social/family history or ROS that are relevant to the chief complaint (e.g., homelessness, father died of MI @ age 40, 20 pack-year smoking history, etc.) may be included in the “history of chief complaint”
Presenting a Patient – Basics
Patient name, age, race, gender
Chief complaint (onset, duration)“Mr. Sullivan is a 24 year-old white man who presents with a 3-day history of a progressively worsening cough, productive of yellow sputum, accompanied over the last 24 hours by sharp, left sided chest pain. “
History of Chief Complaint (O-P-Q-R-S-T; CODIERS)Relevant SH/FH/ROS
Relevant PMH/PSH Current Medications Allergies
Presenting a Patient – Delivery Tips
Be interested and energetic • … and your audience will respond
Know ALL the facts of the story • … but don’t automatically tell it all
Be confident • … never condescending
Use notes • … but don’t read them
Be organized
• … follow a standardized pattern
Use precise language
Positive statements are more powerful than negative statements• “Lungs are clear of wheezes or crackles” is better than “Lung
auscultation showed no abnormalities”
Get to the “bottom line” as quickly as possible• … remembering that this varies with the setting, audience, etc.
Presenting a Patient – Delivery Tips
Avoid redundancy• “On auscultation, the lung sounds were…”
• “On physical exam, the heart was…”
• “The patient states…”
Avoid judgmental language• “The patient is a poor historian…”
• “ This 26 year-old man is a ‘frequent flyer’ in the ED..”
Don’t editorialize• “The nurse kept interrupting the interview to administer
medications, even though I asked to be left alone…”
Presenting a Patient – Delivery Tips
Practice Flexibility to accommodate preceptor preferences
• Frustration is normal
Don’t hesitate to contact us:
Presenting a Patient – Questions?
Primary Care Associates (FM Fellows)Grosvenor 333
fellowsd@oucom.ohiou.edu(740)593-2106
Leonard Harris is a 78 year-old AA male who presents with his daughter, Jill, to the family doctor’s office. Leonard has “no complaints.” Jill has made this appointment to express concerns re: her father’s recent “absent-mindedness”… Student Doctor Schoeny Student Doctor Manzanillo
Practice Case 1:Ambulatory Family Medicine
Primary Care Associates (FM Fellows)Grosvenor 333
fellowsd@oucom.ohiou.edu(740)593-2106
Ashlee Pranso is a 32 year-old white female presenting to L&D reporting, “Really bad pain in my belly.” Student Doctor Crye Student Doctor Parks
Practice Case 2:Inpatient OB/GYN
Primary Care Associates (FM Fellows)Grosvenor 333
fellowsd@oucom.ohiou.edu(740)593-2106
Ms. Brittany Pierce is a 49 year-old white female presenting with a headache 3 days ago, and since that time persistent “dizziness”. Student Doctor Kocoloski Student Doctor Phillips
Practice Case 3:Inpatient Internal Medicine
Primary Care Associates (FM Fellows)Grosvenor 333
fellowsd@oucom.ohiou.edu(740)593-2106