Giving Report / Presenting to the Preceptor
The verbal report should be concise, less than 3 minutes, and follow the correct formatÂ
- Chief Complaint:Â clear and concise presentation of age, sex, reason for seeking care, and duration of symptoms.Â
- HPI:Â narrative, concise, and thorough presentation of positive information and negative pertinent information.Â
- ROS:Â pertinent positive and negative symptoms of the general system, the system(s) above, the system(s) below, and the affected system are stated.Â
- PMH:Â medications and relevant diagnoses are statedÂ
- FH / SH:Â pertinent positive and negative information specifically related to the CC are stated.Â
- Objective:Â All positive findings are stated. Negative findings are stated only if they are related to the CC.Â
- Assessment: State a main diagnosis, a can’t afford to miss diagnosis, and at least four likely differential diagnoses. Â
- Plan:Â Develop a treatment approach including Rx, Tx, Labs, health promotion and patient education, normal disease trajectory F/U, and emergency F/U including red flag signs and symptoms the patient should watch for.Â
School of Health Sciences, Seattle Pacific University