NEW PATIENT Presentation Structure – 7-Minute Limit

A. Data Gathering

1. Name, Age, Last 4
2. Chief Presenting Complaint (Not the Past History)
3. History of Present Illness
a. Past History only if it is RELEVANT to the Chief Complaint (The patient has a history of COPD and presents with shortness of breath.) Watch out for anchoring.

b. History of Present Illness
i. The patient was well until (date)
ii. Tell a chronological history of the illness to this date.

4. Past Medical History RELEVANT & Active Issues. (Don't repeat from the HPI.)
a. Include medication & dose, grouped by problem

5. Family History RELEVANT to the Present Illness. (Don't repeat from the HPI.)

6. Social History (Don't repeat from the HPI.)
a. Military Service History
b. Insurance & Finances
c. Living Situation, Support Systems, DPOA, Living Will, POLST
d. Occupation, hobbies, habits, abuses, diet

7. Review of Systems (Don't repeat from the HPI. Only relevant findings.)

8. Physical Exam (Only pertinent positives and negatives with emphasis on the details.)

9. Diagnostic Data including labs, procedures, radiology, cardiology, consultations

B. Assessment

1. Key Factors for the Admitting Concern
2. Problem Representation
3. Differential Diagnosis A provisional list of diagnoses that explain the most important Key Factors in the Problem Representation for the Admitting Concern (See the example sheet.)

4. Problem List starting with the problem relevant to the Chief Complaint and including social problems such as placement.

C. Plan for each problem on the list as well as the maintenance items of
1. Diet
2. Activity Orders
3. VTE prophylaxis
4. Mobility & Decubitus Prevention (if relevant)
5. Obstructions to progress through the hospital
6. Obstructions to discharge including housing and support and decision making.

D. Life-long Learning
1. Competently answer core, relevant questions about your patient.
2. Identify a learning question for this patient on this day.
3. Demonstrate a working knowledge of the source of the decisions about this patient including recent relevant literature and original sources.

update based on the most up to date information
use medical abbreviations and shorthand
include specific dosages, duation and frequencies iof medications

updated clinical assessment of status and severity for each problem. use guideline based diagnostic and evaluative criteria. integrate this pasted information into the assessment and plan. organize the assessment and plan 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.

A. Data Gathering

1. Name, Age, Last 4
2. Chief Presenting Complaint (Not the Past History)
3. History of Present Illness
a. Past History only if it is RELEVANT to the Chief Complaint (The patient has a history of COPD and presents with shortness of breath.) Watch out for anchoring.

b. History of Present Illness
i. The patient was well until (date)
ii. Tell a chronological history of the illness to this date.

4. Past Medical History RELEVANT & Active Issues. (Don't repeat from the HPI.)
a. Include medication & dose, grouped by problem

5. Family History RELEVANT to the Present Illness. (Don't repeat from the HPI.)

6. Social History (Don't repeat from the HPI.)
a. Military Service History
b. Insurance & Finances
c. Living Situation, Support Systems, DPOA, Living Will, POLST
d. Occupation, hobbies, habits, abuses, diet

7. Review of Systems (Don't repeat from the HPI. Only relevant findings.)

8. Physical Exam (Only pertinent positives and negatives with emphasis on the details.)

9. Diagnostic Data including labs, procedures, radiology, cardiology, consultations

B. Assessment

1. Key Factors for the Admitting Concern
2. Problem Representation
3. Differential Diagnosis A provisional list of diagnoses that explain the most important Key Factors in the Problem Representation for the Admitting Concern (See the example sheet.)

4. Problem List starting with the problem relevant to the Chief Complaint and including social problems such as placement.

C. Plan for each problem on the list as well as the maintenance items of
1. Diet
2. Activity Orders
3. VTE prophylaxis
4. Mobility & Decubitus Prevention (if relevant)
5. Obstructions to progress through the hospital
6. Obstructions to discharge including housing and support and decision making.

D. Life-long Learning
1. Competently answer core, relevant questions about your patient.
2. Identify a learning question for this patient on this day.
3. Demonstrate a working knowledge of the source of the decisions about this patient including recent relevant literature and original sources.

update based on the most up to date information
use medical abbreviations and shorthand
include specific dosages, duation and frequencies iof medications

updated clinical assessment of status and severity for each problem. use guideline based diagnostic and evaluative criteria. integrate this pasted information into the assessment and plan. organize the assessment and plan 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.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 409 boilerplate words
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