Patient Presentation Guidelines

Advance Practice Registered Nurses frequently need to present a patient to another health care provider in a concise manner. Your case presentation is an excellent opportunity to practice patient presentations to a colleague.

Overview:

  • Patient presentations are concise, and brief.
  • Presentation should be completed in 2- 3 minutes unless it is a new patient which may extend up to 5-6 minutes.
  • Delivery should be smooth and succinct. Avoid the inclusion any superfluous information.
  • Format should be made so that the collaborating provider can anticipate your assessment and plan: each piece of information should provide the listener clues regarding your thinking process and differential diagnosis.
  • Notes should be made regarding some pertinent information which may be difficult to remember. The presenter should refer to these notes if necessary, but should not read these notes to the listener.

TYPES OF PATIENT PRESENTATIONS

New Patients: 

  • Includes: Pt name, age, then proceed to Chief complaint. Give brief and pertinent HPI, important and related PMH, PSH, and FH. (you will not include an entire PMH, PSH, and FH as the other provider can read about this at another time)
  • ROS is not included as anything important would have been included in the HPI.
  • PE positive and pertinent negatives,
  • Assessment and plan if you know it, including what diagnostic tests done, and tx that you have previously implemented.
  • Finally, State what your question, or indicate what you are asking for help with. (this should match the chief complaint)

Follow Up

  • The presentation on a follow up may be updating the collaborating provider regarding results of tx plan previously implemented, or results of diagnostic tests ordered previously ordered.
  • You will need to give some information to remind the collaborating provider of what tests or tx were implemented, why these were ordered, and what the results were or response was to the treatment.

Problem Focused:

  • Includes: Pt name, age, chief complaint or problem. Give brief HPI for this problem, with related PMH and medications. (will not be as detailed as for new patients).
  • Next give PE including pertinent positive and negatives. Include any pertinent diagnostic information here
  • Assessment and Plan: presentation is concluded with the assessment and plan, or with the request for tx recommendations from the collaborating provider.

PREPARATION

  • Information Search: have information prepared regarding pathophysiology of the problem and usual tx of the problem
  • Know what questions you have about this particular patient.

PROCESS:

  • Be prepared for this presentation, have information ready, including medications, lab and procedure results.
  • Be concise and complete: expect to have the attention of the listener for less than 3 minutes.
  • Know your question: usually the presentation is formatted so that the listener can anticipate the possible diagnoses. You are guiding them through the case presentation and essentially telling a story. This may be very different from a case presentation done with your preceptor, where you are anticipating your preceptor to have questions about the patient and to discuss/determine the diagnosis and treatment plan with you.
  • Anticipate and Expect questions from the listener. Often it will appear as if the listener is trying to trick you and is only out to identify that you missed some bit of information. In reality it is that this information was missing in the first place or was not completely clear, or that the listener has an idea of the diagnosis and treatment plan and needs more information to confirm this.

TIPS

  • Include only the most essential facts: but be ready to answer ANY questions about all aspects of your patient.
  • Keep your presentation lively.
  • Do not read the presentation
  • Expect your listeners to ask questions
  • Follow the order of the written case report
  • Keep in mind the limitation of your listeners.
  • Beware of jumping back and forth between descriptions of separate problems
  • Use the presentation to build your case.
  • Your reasoning process should help the listener consider a differential diagnosis
 
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