Giving Report / Presenting to the Preceptor

The verbal report should be concise, less than 3 minutes, and follow the correct format 

• Chief Complaint: clear and concise presentation of age, sex, reason for seeking care, and duration of symptoms. 
• HPI: narrative, concise, and thorough presentation of positive information and negative pertinent information. 

• ROS: pertinent positive and negative symptoms of the general system, the system(s) above, the system(s) below, and the affected system are stated. 
• PMH: medications and relevant diagnoses are stated 
• FH / SH: pertinent positive and negative information specifically related to the CC are stated. 
• Objective: All positive findings are stated. Negative findings are stated only if they are related to the CC. 
• Assessment: State a main diagnosis, a can’t afford to miss diagnosis, and at least four likely differential diagnoses.  

• Plan: 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.