ARAULLO UNIVERSITY PHINMA
College of Nursing
CASE PRESENTATION FORMAT
(GENERAL WARD)
I.
Introduction
II. Purpose/Objective -
Learning a skill that you will use for your entire career -- and that skill is to be able to communicate in a way that enables you to present the patient to any other health-care provider in a concise manner. It is like learning another language.
LEARNING GOAL SKILLS KNOWLEDGE ATTITUDE STUDENT CENTERED CLIENT CENTERED
[Link] Complaint (CC) The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant. If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it History of Present Illness (HPI)
IV. -
Present the most important problem first If there is more than one problem, treat each separately Present the information chronologically. Cover one system before going onto the next Characterize the chief complaint quality, severity, location, duration, progression, and include pertinent negatives For ongoing care, present any new complaints.
V. Past Medical History (PMH) Discuss other past medical history that bears directly on the current medical problem.
VI. Past Surgical History Provide names of procedures, approximate dates, indications, any relevant findings or complications, and pathology reports, if applicable Allergies/Medications
VII. -
Present all current medications along with dosage, route and frequency. For ongoing care, note any changes.
VIII. Smoking and Alcohol (and any other substance abuse) Note frequency and duration Social/Work History
IX. -
Home, environment, work status and sexual history
X. Family History - Note particular family history of genetically based diseases XI. Review of Systems (ROS) Present the normal anatomy and physiology Present also what happens to the affected structure/s during the course of the disease Pathophysiology
XII. -
Clearly states the disease process (short/brief, complete and understandable!)
XIII. Physical Exam Include all significant abnormal findings and any normal findings that contribute to the diagnosis. brief, general description of the patient including physical appearance (head to toe assessment) Describe vital signs (including LMP and AOG if applicable.)
NORMAL ACTUAL OBSERVATION SCIENTIFIC EXPLANATION
PHYSICAL APPEARANCE
HEAD EYES
XIV. Diagnostic tests
VITAL SIGNS BLOOD PRESSURE PULSE RATE RESPIRATORY RATE TEMPERATURE NORMAL ACTUAL OBSERVATION SCIENTIFIC EXPLANATION
Laboratory data- provide the actual findings and highlight the abnormal result Discuss the relevance of these abnormal findings in the disease of the patient
LABORATORY TEST
NORMAL VALUE
RESULT
INTERPRETATION
XV. -
Course of treatment
Surgery if any/Medications/Other medical treatment given to your patient Provide the relevance of each treatment/ medications (why it is essential for your patient) COURSE IN THEWARD
DAY 1
PROBLEM DATE INDEPENDENT NSG. ACTION DEPENDENT NSG. ACTION RATIONALE
1.
PROBLEM DATE RATIONALE
1. DAY 2
PROBLEM PROBLEM DATE DATE DEPENDENT NSG. ACTION DEPENDENT NSG. ACTION RATIONALE RATIONALE
PHARMACOLOGIC MANAGEMENT
DA TE GENERIC/ TRADE NAME DOSAGE/ FREQUEN CY/ ROUTE CLASSIFICATI ON INDICATI ON CONTRAINDICA TION SIDE EFFECT S NSG. RESPONSIBIL ITY
XVI. Assessment and Plan (NCP) Scientific Problem Nsg. Dx Explanati Plan on XVII. Discharge Planning
PROBLEM HEALTH TEACHING
Interventi on
Rational e
Outcome
HOME MEDICATION
INDICATION
TIPS: 1. Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient. 2. Keep your presentation lively. 3. Do not read the presentation! 4. Expect your listeners to ask questions. 5. Follow the order of the written case report. 6. Keep in mind the limitation of your listeners. 7. Beware of jumping back and forth between descriptions of separate problems. 8. Use the presentation to build your case.
9. Your reasoning process should help the listener consider a differential diagnosis. 10. Present the patient as well as the illness.
