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
Paint the big picture: synthesize all documentation to give the complete picture of medical decision-making by capturing necessary details tailored to capturing their clinical aspects and contributions, as well as co-morbidities, quality data, etc.

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous sections.

Summarise the salient points. Document your impression of the diagnosis or differential diagnosis.    If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating:

Start with a one-line problem statement or summary statement (See Dr. Strong’s lecture)
__ year old M/ F patient with PMHx of (include all the relevant info/ diagnoses) presented with __ x duration.

Divide into two big categories: New or active medical problems and chronic medical problems.

Always state the likely diagnosis. If you are not sure, use “Probable/ Possible/ Likely/ Suspected”.
Document accurately. e.g., “Sepsis 2/2 to complicated UTI”, not urosepsis.
Always look for precipitating or exacerbating factors for worsening chronic medical conditions.

Calculate relevant scores/ scales for risk stratification:

    TIMI score for chest pain,
    CURB 65 score &/ or PSI/ PORT score for pneumonia,
    NIH stroke scale for stroke,
    GCS scale if AMS (+),
    Wells’ criteria for DVT/ PE,
    CHA2DS2-VASc score and HAS BLED score for Afib, etc.

Describe the workup and management plan for new problems. And also briefly mention the baseline function for chronic medical problems, e.g. Baseline PFT’s in COPD.

[* For pert +/- PE, break them into Present and Absent. For Pertinent +/- labs, imaging/studies: Break them into Done & Pending.]

Write an effective problem statement.
2. Write out a detailed list of problems

From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions.
3. Combine problems

Instead of doing a problem based where you list every single problem, try to combine the problems and either used a system based approach or an approach that links primary problems with secondary problems that are likely caused by the primary problems or go together and are treated together.

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.

PLAN

The final section is the plan, which is where you document how you are going to address or further investigate any issues raised during the review.

Items you to include in your plan may include:

    Further investigations (e.g. laboratory tests, imaging)
    Treatments (e.g. medications, intravenous fluids, oxygen, nutrition)
    Referrals to specific specialties
    Review date/time (e.g. “I will review at 4 pm this afternoon.”)
    Frequency of observations and monitoring of fluid balance
    Planned discharge date (if relevant)


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


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

Write an effective problem statement.

Start with a one-line problem statement or summary statement
__ year old M/ F patient with PMHx of (include all the relevant info/ diagnoses) presented with __ x duration.

Paint the big picture: synthesize all documentation to give the complete picture of medical decision-making by capturing necessary details tailored to capturing their clinical aspects and contributions, as well as co-morbidities, quality data, etc. document thoughts on the salient issues and the diagnosis (or differential diagnosis), based on the information collected.    Summarise the salient points. Document your impression of the diagnosis or differential diagnosis.    If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating:


Divide into two big categories: New or active medical problems and chronic medical problems.

Always state the likely diagnosis. 
If not sure, use “Probable/ Possible/ Likely/ Suspected”.
Document accurately. 
Always look for precipitating or exacerbating factors for worsening chronic medical conditions.

Calculate relevant scores/ scales for risk stratification:

Describe the workup and management plan for new problems. 
And also briefly mention the baseline function for chronic medical problems, 


For Pertinent Physical    exam    findings, break them into Present and Absent. 

For Pertinent    labs, imaging/studies: Break them into Done & Pending.

Write out a detailed list of problems

From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions.

Combine problems

Instead of doing a problem based where you list every single problem, try to combine the problems and either used a system based approach or an approach that links primary problems with secondary problems that are likely caused by the primary problems or go together and are treated together.

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.

PLAN

The final section is the plan, which is where you document how you are going to address or further investigate any issues raised during the review.

Items you to include in your plan may include:

    Further investigations (e.g. laboratory tests, imaging)
    Treatments (e.g. medications, intravenous fluids, oxygen, nutrition)
    Referrals to specific specialties
    Review date/time (e.g. “I will review at 4 pm this afternoon.”)
    Frequency of observations and monitoring of fluid balance
    Planned discharge date (if relevant)


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.