·        Be concise- Learn to communicate key facts in 5 minutes, so others can rapidly help you with the case.  

·        Do not read your clinic note verbatim. Presentation ≠ Documentation.

·        Maximize efficiency in transfer of complex data with use of medical terminology and semantic qualifiers.  

·        Advance learners should ask questions/identify knowledge gap at start, so you can focus preceptor teaching

·        Stay organized, avoid editorial, and do not lose track of the patient’s concerns (cc)


Click the links below for example

SituationGive your listener context, why is the patient here? What type of visit is this? How much time do you have?

·        Context: Age/gender, new patient, f/u care, urgent visit why? coverage for someone, walkin

·        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 – Deliver context and historical facts to help decision making and direct teaching. Avoid diagnosing or deciding on management plans here.

·        Problem List: Starting with the history of active problems helps others to understand the context of the chief complaint. Present the active, relevant problems to define your patient. Include inactive Pmhx ONLY if relevant.  (do not read everything written)

·        Chief Complaint:  YOU MUST Identify what’s the most important pt concern(s) this visit.  This step is critical to avoid a doctor-centered approach to visit 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 asked to come “f/u for CHF medication adjustment”

·        HPI/ROS: clarify here historic features of new symptoms and active disease states.  Then explore secondary concerns (like history surrounding chronic disease management, home bp or fsg results…), list pertinent pos/neg.  Include ROS, functional status/exercise tolerance should always be explored at each encounter.

·        Medications List: ALWAYS

·        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

Assessment/ Plan                             

·        Summary Statement- Always summarize the clinical situation in 1-3 sentences (who is this patient? why are they here? What are notable findings on the H&P?)

·        Then list by problems uncovered- patient’s chief concern is always problem #1 so you don’t forget about the patient. Then prioritize others.  Always define problems only to level of certainty (dyspnea ≠CHF)

·        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