· Be concise- Learn to communicate key facts in 5 minutes, so others can rapidly be informed and become helpful to you and your patient.
· Do not read clinic notes verbatim. Presentation ≠ Documentation. Too much extraneous information will cognitively overload listeners.
· Maximize efficiency in transfer of complex data with use semantic qualifiers and medical terminology (“chronic dyspnea on exertion” instead of “patient says he always feels short of breath when he walks a lot”)
· Stay organized, avoid editorial comments, and do not lose track of the patient’s concerns (cc)
· Advance learners should start with a questions, so you can focus preceptor teaching
Click the links below for example
Situation –Give your listener context, why is this patient here? What type of visit is this? How much time do you have to discuss? How can your preceptor help?
· Context: Age/gender, new vs. f/u patient, urgent care vs. continuity visit, consult, preop…?
· Chief Complaint: Identify what’s the most important pt concern(s) at the start. This doesn’t have to be a physical discomfort, it can be a specific request (testing, rxs), or a worry expressed about a disease. Listing the CC upfront, will help avoid a doctor-centered approach to the H&P encounters. This will ensure that your patient is heard and their concern is prioritized. If the patient is asymptomatic, you should explain why the patient was even asked to come back: “diabetes management”
· If you are running late or have a busy schedule, let your preceptor know. They will be more judicious w teaching and help with patient flow and scheduling.
Background – Provide relevant Pmhx and H&P findings. Avoid discussing differentials/plans during the HPI.
· Problem List: Starting with a prioritize and brief listing of relevant medical problems to help others to quickly understand the patient and the context of the chief complaint. For complex or elderly pts with long lists of active medical conditions as well as extensive Pmhx (inactive conditions), you will need to edit down to not overwhelm the listener.
· HPI/ROS: clarify pt’s history of new symptoms and active disease states, include pertinent +/-. Follow with an exploration of other concerns of yours (hx of chronic disease management, home bp or fsg results, med intake..). Include ROS, functional status/exercise tolerance should always be explored at each encounter.
· Medications List: ALWAYS read out
· Medication allergies: if present
· Family Hx/Social Hx: ALWAYS on new patient visits. Include on follow up visits if relevant
· Physical Exam: VITALS ALWAYS, exam pertinent pos/neg
· Data: describe only new and relevant labs/imaging
· Summary Statement- Summarize the clinical situation in ~3 sentences (who is this patient? why are they here? What are notable findings?)
· Then discuss by priority of problems uncovered- patient’s chief concern is always problem #1. Always define problems ONLY to level of certainty (dyspnea ≠CHF, stomach pain≠ GERD)
· For undiagnosed problems/symptoms/findings- generate 3-5 differential diagnosis and provide clinical reasoning- list most likely, less likely, and “can not miss” diagnoses… then argue for and against each.
· Define plan for each problem –list next steps in diagnostics or treatment
· health maintenance and prevention needs/plans –screening/counseling/vaccinations are reviewed as the last “problem” to every ambulatory evaluation. This is always the last problem in each discussion.
· Define follow up interval/instructions for patient prior to next visit- when is a safe interval to return for followup