Question about oral presentations on rounds...

[ej37]

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Hey all I'm new to third year had a quick question about H &P presentations on rounds. I'm on the internal medicine rotation now.

1) When do you include the "ER course" of a patient you are presenting for the first time? I was told by my first intern to put it at the end of my HPI, and was told by my second to put it right before assessment and plan. including it in the HPI seems to make more sense because if a patient came into the ER with a BP of 250/120 and a potassium level of 2.3 I would that information would be important enough to include there instead of waiting for the Vitals/Lab section, especially because I would naturally tailor the rest of presentation around that info focusing more on things like optho exam, etc... However when I did this at rounds this morning my attending scolded the hell out of me and told me to always present labs with labs and vitals with vitals...

2) Along the same lines, say you are going an H & P one day but present it to the attending the next day. Where do you include "overnight events", i.e. your SOAP note so to speak of the previous 24 hours events? Again, I have been told a couple of things, first that I should include this right before the assessment and plan, and another intern told me to first do a full H&P, then another soap note with afterwords potentially with a second assessment and plan.


Sorry for the long post, thanks to anyone still reading and who might be able to clear some of this up for me!

 

[turkeyjerky]

Hey all I'm new to third year had a quick question about H &P presentations on rounds. I'm on the internal medicine rotation now.

1) When do you include the "ER course" of a patient you are presenting for the first time? I was told by my first intern to put it at the end of my HPI, and was told by my second to put it right before assessment and plan. including it in the HPI seems to make more sense because if a patient came into the ER with a BP of 250/120 and a potassium level of 2.3 I would that information would be important enough to include there instead of waiting for the Vitals/Lab section, especially because I would naturally tailor the rest of presentation around that info focusing more on things like optho exam, etc... However when I did this at rounds this morning my attending scolded the hell out of me and told me to always present labs with labs and vitals with vitals...

2) Along the same lines, say you are going an H & P one day but present it to the attending the next day. Where do you include "overnight events", i.e. your SOAP note so to speak of the previous 24 hours events? Again, I have been told a couple of things, first that I should include this right before the assessment and plan, and another intern told me to first do a full H&P, then another soap note with afterwords potentially with a second assessment and plan.


Sorry for the long post, thanks to anyone still reading and who might be able to clear some of this up for me!

These are difficult issues with presenting patients that all med students struggle with. The correct way really depends on the attending's preference, which will differ and you will never be able to anticipate. I really wouldn't stress about it too much.

 

[PTPoeny]

Yup. Ask your attending.

The general format that most of my attendings have preferred for a new patient when the H&P was done the day before is:
(different attendings want the ER part in different places)

One-liner
CC
HPI
PMH
PSH
SH
Meds
SOAP note

 

[ej37]

Yup. Ask your attending.

The general format that most of my attendings have preferred for a new patient when the H&P was done the day before is:
(different attendings want the ER part in different places)

One-liner
CC
HPI
PMH
PSH
SH
Meds
SOAP note

I see. So I'm assuming you also list the previous days Vitals/PE/Labs after meds and between the soap note? It sounds like you only do 1 Assessment and plan in total? Thanks.

 

[PTPoeny]

I see. So I'm assuming you also list the previous days Vitals/PE/Labs after meds and between the soap note? It sounds like you only do 1 Assessment and plan in total? Thanks.

Most attendings so far haven't wanted to know the admission PE, just the one from this AM and I put all the labs in the lab section of the SOAP note. Just one A&P.

One attending had me present the PE of the SOAP note saying "this morning pt displayed x which differed from y seen on admission (or in the ER)". As for vitals, some have wanted the ER course in the HPI, most have not as if it has been less than 24 hours the vitals are in my vitals presentation anyways.

But you really just have to ask.

 

[ej37]

Most attendings so far haven't wanted to know the admission PE, just the one from this AM and I put all the labs in the lab section of the SOAP note. Just one A&P.

One attending had me present the PE of the SOAP note saying "this morning pt displayed x which differed from y seen on admission (or in the ER)". As for vitals, some have wanted the ER course in the HPI, most have not as if it has been less than 24 hours the vitals are in my vitals presentation anyways.

But you really just have to ask.

Interesting, if I were to present it that way I'd get a book thrown at my head. Like you all have been saying I guess its really just attending/institution dependent. I don't if any residents or attendings read this forum but if they do it'd be interesting to get their input!

 

[DocEspana]

I can tell you it varies by atteding and even situation. We have morning rounds where we just cover new patients from the ER overnight. That attending wants *everything*.

one liner
CC
Admitting diagnosis
HPI
PMHx
PSHx
SHx
PsychHx
Allergies
Current meds
Vitals at ER presentation
ER Course
Most recent vitals
full PE
Full labs so far
A/P

Then on rounds on all patients, just a few hours later, the attendings (occasionally the same guy) wants a much more condensed "a really good HPI, todays vitals, pertinent physical findings, new labs since yesterday and A/P"

its context dependant and physician dependent. I know certain attendings want that full round in the late morning/early afternoon to be more conversational (formal, but conversational) while others want it to be rigidly formatted. Still, thankfully rhey all agree on how much detail they want us to cover.

 

[RySerr21]

yea this is a struggle to figure out. I think it makes sense just to do it chronologically. I do a one liner/CC and give a brief summary of how it was described to me from the ER...then i just flow into the hpi as I recieved it... i do an update of overnight events/how the patient is doing that morning in the assesment/plan. i have good feedback with this format so far, but as others have said its totally dependent on your attending. ive never had someone tell me not to do it this way tho.

 

[werd]

the most common place to have the ER course is at the end of the HPI. the way i would usually present significant overnight events is as part of the A/P, ie "this is what we initially thought and ordered, but then this happened so..." or "kidney failure, this is what we think, this is what we ordered, Cr is up/down to x this morning." if there weren't significant overnight events or meaningful updates, just a sentence like "she was stable overnight, still complaining of the same symptoms this morning, physical exam unchanged."

as noted above, some attendings have specific preferences about this stuff. others just want the information in a coherent fashion.

 

[colbgw02]

I'd just like to point out that, on the main page, the abbreviated title for this thread reads:

"Question about oral..."

 

[officedepot]

.

 

[45408]

I can tell you it varies by atteding and even situation. We have morning rounds where we just cover new patients from the ER overnight. That attending wants *everything*.

one liner
CC
Admitting diagnosis
HPI
PMHx
PSHx
SHx
PsychHx
Allergies
Current meds
Vitals at ER presentation
ER Course
Most recent vitals
[limited] PE
Full labs so far
A/P

Then on rounds on all patients, just a few hours later, the attendings (occasionally the same guy) wants a much more condensed "a really good HPI, todays vitals, pertinent physical findings, new labs since yesterday and A/P"

its context dependant and physician dependent. I know certain attendings want that full round in the late morning/early afternoon to be more conversational (formal, but conversational) while others want it to be rigidly formatted. Still, thankfully rhey all agree on how much detail they want us to cover.

and when you present on surgery, you should include the bolded topics only


In general, different attendings want different presentations. Some hate it when you "give away" the ending. Others hate it when you included the relevant PMH in the one-liner. Others want you to cut to the chase with the one-liner (78 y/o M with a h/o CHF, COPD, CKD presents with SOB and worsening edema).

 

[Gastrapathy]

and when you present on surgery, you should include the bolded topics only


In general, different attendings want different presentations. Some hate it when you "give away" the ending. Others hate it when you included the relevant PMH in the one-liner. Others want you to cut to the chase with the one-liner (78 y/o M with a h/o CHF, COPD, CKD presents with SOB and worsening edema).

When you present on surgery, you should probably include the past surgical hx and relevant labs.

 

[45408]

When you present on surgery, you should probably include the past surgical hx and relevant labs.

I usually don't split the PMH and PSH, so it's just rolled into the PMH. If my intro includes "complicated history of previous abdominal operations," then I'll separate it out and enumerate them. Otherwise, it'll read more like:

1. CAD s/p CABG
2. DJD s/p R total knee arthroplasty
3. Rectal CA s/p APR