· Be concise- Learn to communicate key facts in 5 minutes, so others can rapidly be informed and become helpful to you.
· Do not read clinic notes verbatim. Presentation ≠ Documentation. Too much extraneous information will cognitively overload your listener
· 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 comments, and do not lose track of the patient’s concerns (cc)
Click the links below for example
Situation –Give your listener context, why is the patient here? What type of visit is this? How much time do you have?
· Context: Age/gender, new or f/u patient, urgent care, coverage, consult, regular f/u …?
· Chief Complaint: YOU MUST Identify what’s the most important pt concern(s) at the start. This doesn’t have to be a medical complaint, it can even be a request. 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 even asked to come “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 – Deliver context and historical facts to help decision making and direct teaching. Although tempting avoid diagnosing or deriving plans during the HPI.
· 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. For complex ps with multi-morbidity, include inactive Pmhx ONLY if relevant to visit.
· 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- 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 priority problems uncovered- patient’s chief concern is always problem #1 so you don’t forget about the patient. 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