My first oral presentation on the wards was pretty rough; I did not know where to focus it, and organized it by what I thought was the most pressing concern and sort of in a SOAP note format. The intern I was working with on thoracic surgery introduced me to the format they typically present in for presenting a patient post-operatively – much more organized than what I was doing before. Also, there are many patients to round on, and attendings only want to hear the pertinent matters.The layout goes something like this:
[Name] is a X y/o male/female who is s/p [operation] POD#(post-op day). No acute events overnight. Pain is well-controlled on [pain medications].
Neuro: Details about pain control, dosages.
CV: medications patient is on for prophylaxis, any CV ROS symptoms. Adverse events listed here.
Respiratory: Details about chest tubes if inserted, drainage, output.
GI: Feeding status (ie NPO, NG tube, etc.).
Renal: Urine output, Foley catheter if applicable, electrolyte abnormalities.
Heme: Hemoglobin/hematocrit, anticoagulant prophylaxis if applicable.
ID: Details about infection prophylaxis, WBC count if high/abnormal.
The assessment/plan is the most important part of your oral presentation. Be sure to address all the organ systems as listed above, namely information for medications, intake/output, and what orders you would like to place/discontinue.
