We call it multiple things - “presentation”, “sign out”, etc - but it all composes of the same thing. Who is the patient and what is going on with him/her? Why are they in ICU? What needs to be done?
The who/what/why/how varies in the way it’s presented. For some people it can be short and sweet (i.e., “Mr. Jones is a 56 year old vasculopath that had a carotid endartectomy”) or long and detailed (i.e. “Mr. Jones is a 56 year old with HTN, DM with a history of a L CER that presented to PFH with palpitations, worsening in nature, and was found to have carotid stenosis on the right, taken to the OR with Dr. James on the 15th for a CER”). While you’ll get differing opinions on how to do things the most important thing to do despite how much you present is know everything about the patient.
Below, you’ll see a format for knowing everything about the patient - it’s something you should go through in the beginning every single time you see your patients. As you grow more experience, you can narrow this down to only the pertinent information. But in the end you are the most knowledgeable person about your patient. You have spent the most brain power and energy so making sure you intentionally study a patients chart is important.
Check out our podcast on the assessment oriented presentation:
As a new trainee/student, it’s better to know a LOT about one patient rather than a little about many.
Our patient: greg
Gregory Greg is a 60 year old male with abdominal pain. You go into his room and interview him.
the full presentation
Do this for your attending.
HPI (mnemonic: CODIERS)
Past Medical History
Past Surgical History
Current Drugs (Rx)
Physical Exam - all objective (not your interpretation)
Differential diagnosis: must choose 3
What are you gonna do about it?
the assessment oriented presentation: provider to provider or quick sign out
Provide assessment - doing this first allows listener to cue in to relevant details and avoids cognitive overload
Make your asks known - so they know where they fit in the patient's care plan
Persuade listener that your asks are appropriate so they will help you care for the patient
SBAR communication: for nurse to provider/provider to nurse
Situation: briefly describe the situation; give succinct overview
Background: Briefly state pertinent history; what got us to this point?
Assessment: summarize the facts; what do you think is going on?
Recommendation: What are you asking for? What needs to happen next?