Presenting

[deedubs]

Hi all,
Just started my psych rotation and am really enjoying it. Thinking about doing it for residency. My attending are pretty informal but I''d like to be able to give a really good presentation. What's a good structure to use when presenting a new patient? Also how about for updates on old patients?
Thanks

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[F0nzie]

Describing current statuses usually helps attendings conceptualize a new patient. ie. Mr. Mrs. so and so is a 36 y/o caucasian male/female, he/she is married/divorced/separated, employed/unemployed/retired/disabled, with past psychiatric hx of X, presents today for X. If they are admitted to a medical floor note, the date of the admission and reason for admission.

Note how they arrived/who brought them, current circumstances and stressors, current symptoms (depression,mania,delusions, AVH, SI/HI). Past psych hx, family hx, medical hx, substance abuse hx. legal and or hx of physical/verbal/sexual abuse. MSE. Biopsychosocial formulation and plan.

 

[deedubs]

Thanks Fonzie.