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