med-format

Patient Presentations Part I - Organization is Key

One thing I have struggled with during my clinical years is the patient presentation.  Sometimes I am told I include too much information, sometimes not enough.  After tons of feedback, advice from residents/fellows, and much trial and error I have come up with a method that seems to work well for patient me.  Obviously you can’t please everyone, but I find that this is a good starting point.  I wanted to share my method with all of you who may also struggle with presenting patients.

There are three components to my system: the SOAP format, creating single statements for each component of your presentation, and writing down more thorough data incase you are asked. So what does that look like? Well, like this:

Each morning I print out a rounding report, then fold it over and organize my presentation.  This also helps me organize my thoughts and has made me a better student clinician.  

At the top of each page I write a summary statement, in the format of:

 Age + Ethnicity + Gender + Past Medical History + Admit Date + Chief Concern and/or Diagnosis

Starting with a statement like this helps to orient the team and I to the patient.  You should only include the past medical history and risk factors that pertain to the current problem (we don’t need to know that there is a history of toe fungus or a tonsillectomy when the patient was 7, unless, of course, it is pertinent to the current problem).  When presenting, you can connect the above information into a quick patient summary.  Examples might include:

- This is Mr. Smith, a 48 y.o. WM w/PMH of CML and alcohol dependence who was admitted on the 17th with progressive abdominal pain

- This is Mrs. Jones, a 32 y.o. AAW w/PMH of sarcoidosis who presented for symptomatic bradycardia

- This is Mr. Johnson, a 69 y.o. Native American male w/PMH of CAD s/p CABG in 2003, HTN, HLD, DMII and a 40 pack year smoking history who presented for unstable angina

So that is starting the presentation.  See the next 4 parts for the rest.