Opening Statement
Brief statement of chief complaint and why patient was admitted. Include pointed and relevant historical information.
Source
Briefly note if/why the patient cannot give reliable history. Note any information sources besides the patient.
Present Illness
The differential diagnosis you considered should guide what you include. Consider starting with: “…usual state of health until…” Be chronologically organized and clear without analyzing. Remember OPQRST: Onset, Palliate/Provoke, Quality, Region/Radiation, Symptoms (associated), Temporal aspects. Include elements of past history (with supporting studies and therapeutic interventions), meds, family history, social history (including psychosocial factors) that specifically contribute to the Present Illness. Include pertinent positives and negatives to make the listener understand your DDx. Only include ER course if it significantly affects/alters triage or immediate treatment decisions prior to coming to your unit. Report facts and events, NOT ER diagnoses.
Other History
Important PMH (with supporting history/data). Exclude minor diagnoses without impact on current care. Important meds with doses of relevant ones. Omit unimportant medications. Allergies, Focused FH/SH/ROS. Do not repeat previously stated information.
Physical Exam
Always include general appearance and specific vitals Include pertinent elements of exam and any abnormal findings. Remainder may be noted as “unremarkable.”
Labs/Data
Include pertinent or otherwise significant labs/studies Start with basic blood tests first: CBC→Chem→Coags→Urine→EKG→Rad→Others OK to mention other tests as being “normal.”
Synthesis
Consider beginning with: “And in summary…” but… Assess and synthesize, don’t summarize and regurgitate. Demonstrate YOUR thinking about the patient specific differential diagnosis. If multiple issues present, weave together or discuss lesser issues in problem list below.
Enumerated Problem List
Start with most important problem first. Use most specific label for the problem you can. Avoid labeling a problem solely by its system. Include your understanding of the cause of the problem. Include a specific plan for addressing it