Events: Report any clinical events over past 24 hours-include procedures, key new test results, and input from consult services, SW, PT/OT. Talk to the patient, nurses and cross-cover intern. Review chart for orders/ notes from cross-cover and consultants/ ancillary services.
Status of Previous Symptoms/ New Symptoms: Update on previous symptoms and new symptoms over the last 24 hours.
Vital Signs: Report trends as well as current values for T, P, BP, RR, SaO2 I&O: Report totals as well as relevant breakdown for both intake and output. Report weight and trends in net fluid balance over preceding days.
Physical Exam: State important new physical findings, and status of previous findings. Give level of invasion (Foley, IV, ETT, etc.) and number of days for each. Be prepared to defend the appliances and to make the case that no iatrogenic complication has occurred (infection, thrombosis, pneumoTx, etc).
Medication List: Run the generic drug list daily (taken from MAR) to avoid inappropriate dosing and reduce polypharmacy as soon as possible. Are doses and intervals appropriate for renal/hepatic function? If it takes too long to run the drug list, the drug list is probably too long.
New Lab/Imaging Results: Report new lab data including status of crucial lab tests (i.e. collected but not run yet). If a lab is not important enough to report, it probably was not important enough to get.
Assessment and Plan: Summarize the patient’s medical problems and then present a prioritized problem focused discussion of the major issues. The diagnostic aspect of the problem should be stated first including a narrowed differential diagnosis if relevant, analysis of what you think is going on and why, followed by the diagnostic and treatment Plan. Disposition must be included as a problem, as well as any relevant social, discharge, follow-up and end-of-life care issues. Multi-disciplinary Input (RN, Pharmacist, etc.) should be included in all relevant aspects of the assessment and plan.
Patient Involvement/Education: Does the patient and/or family understand and agree (Informed Consent)?
Questions: Probe the attending/ resident for any additional information that you require to help fill in the blanks and address your learning needs. Plan to answer questions other team members have.
Select: Choose a case-related issue for your self-study and be prepared to discuss what you learned the following day.