Presenting the Pediatric Patient

This is intended as a practical guide for making presentations of new or existing patients on either rounds or sign-outs.  The purpose of these presentations is to make the listener aware of the present situation, how things came to be this way, and what you intend to do about it.
 

New Patient

If a patient has just been admitted, a full presentation should be made.  In general, it follows the format of the history and physical, with each element in the same order.  After recounting the initial history, vital signs, and physical exam, summarize the initial assessment and plan.  Then continue as below, describing the interim hospital course, present vital signs, physical exam, labs, and an updated assessment and plan.  As always, present the assessment and plan organized by system, with the systems presented in order of importance.  The entire presentation for a new patient should be between five and ten minutes long.  If new team members are present, existing patients should be presented in this format for the sake of continuity.

Existing Patient

If the team has already heard the initial presentation once, the daily presentations can be made shorter.  The initial presentation and hospital course are compressed down to a few sentences.  State the patient's name, how long they have been in the hospital, why they are here, and then begin a presentation following the form of a SOAP note.

Sign in/out

Sign in/out, while less formal, must be sufficiently detailed to transfer patient coverage responsibilities from one care provider to another.  It is generally more brief than formal rounding.  The presentation concentrates on practical issues, particularly what must be followed up, monitored, and adjusted in the immediate future.  An effort should also be made to project likely events during the next shift, and make plans for all contingencies related to the patient's condition, such that when they occur, a plan is already in place.  The weight should be stated so that no one has to go searching in case emergency meds are needed.  It is also important to state which attending is responsible for the patient, and who to call if there are problems.

Acknowledgements

Zack, BG.  1982.   A guide to pediatric case presentationsResident and Staff Physician (Nov):71-80.
 
General Pediatrics
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Last modification: February 21, 1998