How to Present a Patient to your Attending Physician or Team Members

Appendix #4:

New Patient H&P or Hospital Admit or New Consult

• Pt identification/intro: “Pt is a 62 y/o white male alcoholic who presents with acute abdominal pain.
• CC + HPI: OLD CARPS. Onset, location, duration, character, aggravating, relieving, temporal (pert pos/neg), severity
• “T” in carts is amplified for pertinent positives and negatives from the hx + medical records review + ROS
• MASH: Medications, Allergies, Surgeries, Hospital Admissions/Major Medical Diagnoses
• FISH; Family Hx. Immunizations and Preventative (Females ask LMP/contraception/GPAL; children ask development).
• Social (HEEADSSS as approp). Habits (Drugs/Tob/ETOH).
• ROS, as pertinent (some were asked in #3 above). There are a maximum of 14 systems
• Vital Signs, followed by Physical Exam
• LABS.  Imaging Studies. Consultation opinions/procedures
• Assessments, by number (= problems + DDx + supportive logic). Keep them numbered the same every day.
• Plan. Each individual assessment gets an individual plan.

Daily Hospital Rounds

• Pt ID/intro: “Pt is a 62 y/o white male with the following problem list: (example: pancreatitis, acute alcohol withdrawal syndrome, HTN, guaiac + stool, Leukocytosis, elevated transaminases, elevated lipase.
• Brief summation of prior days, with current hx of the past 24 hours.
• Pertinent positives and negatives of the hx, but only if pertinent (Able to pass gas, No chills or SOB)
• ROS only as pertinent (generally done with pert+ and Pert-)
• Vital Signs, followed by Physical Exam
• New Labs, imaging, and consultation opinions/procedures, contrasting values with old data
• Assessment (=problems list + DDx + supportive logic)
• Plan. You will list your plan after each individual assessment.

Clinic Visit of an existing patient

• Pt ID and chief complaint (CC)
• OLD CARPS
• Pertinent pos and neg (the “P” = “T” in OLD CARTS), which = pertinent ROS!
• MASH only if it adds to the presentation
• FISH only if it adds to the presentation
• VS, Physical Exam, directed to the complaint and appropriate regions
• Assessment of the CC, with DDx and supportive logic. Add other A’s only if pertinent or active
• Plan for the CC. Add other P’s for other pertinent A’s.

These 3 styles of presentation depend upon the situation: new patient, existing hospital patient on daily rounds, or an outpatient follow-up visit. These are summarized in chart form below. At the very bottom is a summarized summary, suitable for laminating, folding, and putting into your pocket. You will find it makes you look like an honors student on rounds.