Transcript Powerpoint - Presenting a Patient

Presenting a Patient - Guidelines and Tips
CORE Presentation Adapted by Primary Care Associates
July 5th, 2011
Presenting a Patient – Premises
 Purpose: To concisely convey information to another
health care provider
 Present information needed to develop a basic
understanding of the patient’s current state of health
 This fundamental skill will be part of your professional
communications for the remainder of your career
 Just as with documentation, standardized format enhances
clarity and minimizes confusion
Presenting a Patient – Premises
 The format of a formal Patient Presentation differs
according to:
• the service (ambulatory family medicine, surgery, emergency
medicine, etc.)
• the setting (hallway, exam room, “rounds discussion” table, etc.)
• the listener (preceptor, resident, department staff, etc.)
 TIP: Ask the preceptor/resident about oral case
presentation guidelines at the start of the rotation
Presenting a Patient – Basics
 Rule of thumb: BE BRIEF
 Family history, social history and review of systems are
frequently excluded from the case presentation
• Especially the “acute problem” presentation (ED, UC, FM)
• However, ALL details should be investigated in case they are
significant
 Elements of the social/family history or ROS that are
relevant to the chief complaint (e.g., homelessness, father
died of MI @ age 40, 20 pack-year smoking history, etc.)
may be included in the “history of chief complaint”
Presenting a Patient – Basics
 Patient name, age, race, gender
 Chief complaint (onset, duration)
“Mr. Sullivan is a 24 year-old white man who presents with a 3-day
history of a progressively worsening cough, productive of yellow
sputum, accompanied over the last 24 hours by sharp, left sided
chest pain. “
 History of Chief Complaint (O-P-Q-R-S-T; CODIERS)
 Relevant SH/FH/ROS
 Relevant PMH/PSH
 Current Medications
 Allergies
Presenting a Patient –
Delivery Tips
 Be interested and energetic
• … and your audience will respond
 Know ALL the facts of the story
• … but don’t automatically tell it all
 Be confident
• … never condescending
 Use notes
• … but don’t read them
 Be organized
• … follow a standardized pattern
Presenting a Patient –
Delivery Tips
 Use precise language
 Positive statements are more powerful than negative
statements
• “Lungs are clear of wheezes or crackles” is better than “Lung
auscultation showed no abnormalities”
 Get to the “bottom line” as quickly as possible
• … remembering that this varies with the setting, audience, etc.
Presenting a Patient –
Delivery Tips
 Avoid redundancy
• “On auscultation, the lung sounds were…”
• “On physical exam, the heart was…”
• “The patient states…”
 Avoid judgmental language
• “The patient is a poor historian…”
• “ This 26 year-old man is a ‘frequent flyer’ in the ED..”
 Don’t editorialize
• “The nurse kept interrupting the interview to administer
medications, even though I asked to be left alone…”
Presenting a Patient –
Questions?
 Practice
 Flexibility to accommodate preceptor preferences
• Frustration is normal
 Don’t hesitate to contact us:
Primary Care Associates (FM Fellows)
Grosvenor 333
[email protected]
(740)593-2106
Practice Case 1:
Ambulatory Family Medicine
 Leonard Harris is a 78 year-old AA male who presents
with his daughter, Jill, to the family doctor’s office.
Leonard has “no complaints.” Jill has made this
appointment to express concerns re: her father’s recent
“absent-mindedness”…
 Student Doctor Schoeny
 Student Doctor Manzanillo
Primary Care Associates (FM Fellows)
Grosvenor 333
[email protected]
(740)593-2106
Practice Case 2:
Inpatient OB/GYN
 Ashlee Pranso is a 32 year-old white female presenting to
L&D reporting, “Really bad pain in my belly.”
 Student Doctor Crye
 Student Doctor Parks
Primary Care Associates (FM Fellows)
Grosvenor 333
[email protected]
(740)593-2106
Practice Case 3:
Inpatient Internal Medicine
 Ms. Brittany Pierce is a 49 year-old white female
presenting with a headache 3 days ago, and since that
time persistent “dizziness”.
 Student Doctor Kocoloski
 Student Doctor Phillips
Primary Care Associates (FM Fellows)
Grosvenor 333
[email protected]
(740)593-2106