7 Minute – NEW ATTENDING OLD PATIENT – Presentation

1. Opening Statement: This is *** whose primary ongoing problem is *****

Tell a chronological history of the illness to this date.

2. Overnight Update

"Since yesterday, the following occurred"

a. Update on urgent events (RRT, Code, Transfer)

b. Update on new consultations

c. Update on new labs and diagnostic tests

3. Current Status - "This morning"
a. Update on how the patient feels
b. New patient concerns arising over night
c. Review of important physical findings
i. Vital signs including weight & changes in weight
ii. Fluid status including net fluid status today & over the hospital course 

iii. Physical Exam findings & changes RELEVANT to the problem list
d. Labs from today including point of care blood sugar testing
e. Procedure & Radiology results if not already reviewed


4. Assessment and Plan Section

Use    this    format:    
-Name of Problem
-An    Updated clinical assessment of status and severity    of    the    listed    problem
- guideline based diagnostic and evaluative criteria. 
- integrate subjective and objective    data    /    information. 

Organize this    section    by    problem,    which    each    having    its    own    brief assessment and plan

Order    this    section    by    problem in order of severity and acuity. 

Each problem should have a clinical assessment of that problem's status and then orders and plan to address that problem. 

Use evidence based and guidelines for assessment. 

Ensure orders are evidence based and gold standard for each problem.

Use the most updated information for each problem and include problems or abnormalities not addressed.

Ongoing Problem List    Section:

Key Factors
Problem Representation for ongoing and new problems

Problem List Adjustment as new problems occur or as some problems change relevance or status

Maintenance Issues in your problem list

Diet

Fluid Orders, Current orders & volume status 
Foley Catheter 
Telemetry
Central Lines
Activity Orders, BMAT, PT, OT & Compliance with activity orders 
Skin Integrity 
Bowel Status 
ix. 

Adjustments required relevant to NPO, blood sugars, anticoagulation, preparation for procedures

Discharge    Section
Discharge Planning
Discharge location
Medications & Medication Reconciliation including drug interactions 
Outpatient Follow-up Required
DME & 02

Pending Issues Section

5. Life-long Learning
a. Competently address core question and identify a learning question for the day.