OPENING/INTRODUCTORY SENTENCE
Attempt to encapsulate the entire patient assessment in 1-2 sentences.
- Stable or unstable? Mild/Moderately/Severely unwell?
- Total duration of illness and 1-3 key symptoms.
- Chronological progression – acute, chronic or acute on chronic, episodic or persistent, stable or progressive
- Likely diagnosis (otherwise state ‘diagnosis uncertain’ with most important diagnoses to potentially exclude)
THE STORY
- This is the classical presentation of history and physical examination taught in medical school
- Before picking up the phone or putting pen to paper, attempt to create a logical structure in the presentation
- Do not introduce irrelevant components in the middle which do not relate to the current problem or its management. They can be optionally included at the end for completeness
- It is important to indicate how rapidly the situation is deteriorating and its severity including current complication and responsiveness to prior treatment
THE CONCLUSION
This is essential. It conveys what needs to be done, not what just is known.
- Likely diagnoses or important diagnoses to exclude
- The investigative strategy to rule out serious conditions
- Treatments already commenced and time for review
- Suggested disposition
- Follow-up and monitoring and in what time frame
- Contingency plans depending on results of investigations and response to treatment