Inpatient Presentations

Clinical oral presentations vary based on clinical setting, specialty, attending, and context. Here is a general outline that can help you gather everything you would need to know about a patient. This outline is somewhat parallel to I-PASS, a common menumonic for handing off patients.

Illness Severity - Stable, watch, or unstable - if your patient is not stable they should be discussed sooner

Subjective (History) - varies based on attending familiarity

One liner: age/sex and reason for admission (55 y/o male with KEY HISTORY admitted for TOP PROBLEM)

*Code Status: consider including in one liner if patient is unstable or DNR/DNI

Management-changing updates (s/p thoracentesis): most attendings don't want to wait for important updates

*Full History: choose this if the patient has not been formally presented to the patient yet 

HPI: why did the patient seek medical help (symptoms/OLDCARTS/OPQRST)? What is the larger context of this particular problem?

PMH, PSH, FH, SH, Allergies, Medications (home), ROS (if needed)

*Brief Hospital Course: alternative to full history if there is a new attending and the patient has been admitted for a while.

Subjective Updates (overnight events): the patient's problem-focused symptoms in the context of why they are admitted and any overnight events

Objective (data) - varies based on the attending and your role on the team

Vitals: prefer summary statements for normal (afebrile, non-tachycardic, normotensive) and range values with trends for abnormal

Exam: YOUR exam that you did TODAY

Labs: prefer summary statements for normal (CBC and CMP within normal limits) and exact values with trends for abnormal

Imaging: anything in the 24-48 hours, US, XRAY, CT, MRI

Micro: always double check any pending cultures

Diagnostics/Procedures/Pathology: any surgeries, biopsies, invasive procedures  

Assessment/Plan (medical decision making) - varies based on the attending and your role on the team

Brief overall assessment: what do you think is going on and what are the barriers to discharge? Keep it short.

*Update Summary: for complicated patients, I sometimes highlight recent updates separately in addition to below

Problem(s): be specific as possible, diagnosis with qualifiers > diagnosis >> symptom. Every medication/intervention should have an associated problem

Medical reasoning: your thoughts on what is going on for this problem

Key data: summarized and trending, not verbatim. Biopsy > imaging > labs

Consultant Recommendations: specialists that are following and what they recommended most recently

Plan: all medications and changes

*Discharge Planning: consider including if things need to be coordinated

Other: Diet, DVT prophylaxis, Code Status, Disposition (intended DC date)

Handoffs Tools (more to come later)

SBAR (Wikipedia Page)

Situation

Background

Assessment

Recommendation

I-PASS 

Illness severity 

Patient summary 

Action list 

Situation awareness and contingency planning 

Synthesis by receiver