Columbia’s SBAP AMBULATORY CASE PRESENTATION FORMAT (borrowing on concepts from IHI’s SBAR)
· Be concise- aim to get the key facts across in 5 minutes.
· Advance learners should ask questions/identify knowledge gap early so you can focus your PIC’s teaching
· Do not read your note verbatim, to maximize accuracy and efficiency in transfer of complex information, you need to use medical terminology and prioritize pertinents
· Stay organized avoid editorial comments. Do not lose track of the patient’s concerns (chief concern or complaint)
Situation –Give your listener context, why is the patient here? What type of visit is this. How much time do you have to chat
· 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 your time, or help w scheduling.
Background – give your preceptor the context and historical facts to help decision and teaching. Do not diagnose or derive management plans during the HPI.
· Problem List: Present the active, relevant problems to define your patient. Include inactive Pmhx ONLY if relevant. (do not read everything)
· Chief Complaint: YOU MUST Identify what’s the most important pt concern this visit. If TRULY no pt CC, then the CC can also be just “f/u CHF medication adjustment”
· HPI/ROS: clarify CC and related history first, then explore secondary concerns (can include your own like DM mgmt. etc), list pertinent historical pos/neg. Include ROS, functional status/exercise tolerance is always important to give context.
· Medications List: ALWAYS
· Allergies: if pertinent
· Family Hx/Social Hx: present always on new patient visits. For follow up visits, include if relevant
· Physical Exam: VITALS ALWAYS, exam pertinent pos/neg
· Data: recent labs/imaging
· 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- CC 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, do not miss ddx… 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
· Define follow up interval/instructions for patient prior to next visit- when is a safe interval to return for followup