SBAP Ambulatory Case Presentation

(with concepts borrowed from IHI’s SBAR)

See this cute video explanation of SBAR!

General Principles

  • Be concise - Learn to communicate key facts in 5 minutes, so others can be informed rapidly and become helpful to you and your patient.   
  • Do not read clinic notes verbatim. Presentation ≠ Documentation. Too much extraneous information will cognitively overload listeners.
  • Maximize efficiency in transfer of complex data by using semantic qualifiers and medical terminology (i.e. say “chronic dyspnea on exertion” instead of “patient says he always feels short of breath when he walks a lot”).
  • Stay organized, avoid editorial comments, and focus on the patient’s concerns.
  • Advanced learners should start with a clinical question to focus preceptor teaching.

Headings below are links - click for examples of these aspects done well and examples that need improvement.

Situation

Give your listener context: Why is this patient here? What type of visit is this? Are you pressed for time, or do you want to have an in-depth discussion? How can your preceptor help?

  • Context: Age/gender, new vs. established patient, urgent care vs. continuity visit, consult, preop…?
  • Chief Concern: Identify what’s the most important patient concern(s) at the start. This doesn’t have to be a physical discomfort, it can be a specific request (testing, prescriptions, forms), or a worry expressed about a disease. Eliciting and listing the CC up front will help avoid a doctor-centered approach to the H&P encounters, ensuring that your patient is heard and their concern is prioritized. "Follow up" is not a chief complaint, and neither is "establishing care." Dig deeper. If the patient is truly without a concern, you should explain why the patient was asked to come back, or the problem you spent the most time on: "Diabetes management."
  • If you are running late or have a busy schedule, let your preceptor know. They will be more judicious with teaching and help with patient flow and scheduling.

Background

Provide relevant past medical history and H&P findings.  Avoid discussing differentials/plans during the HPI.

  • Problem List: Starting with a prioritized and brief listing of relevant medical problems to help others to quickly understand the patient and the context of the chief complaint. For complex or elderly patients with long lists of active medical conditions as well as extensive inactive conditions, you will need to edit down to not overwhelm the listener.
  • HPI/ROS: Clarify patient's history of new symptoms and active disease states, include pertinent positives and negatives. Follow with an exploration of other concerns of yours (chronic disease management, home BP or FSG results, med adherence). Include ROS. Functional status/exercise tolerance should always be explored at each encounter.
  • Medications List: ALWAYS review a complete medication list.
  • Medication allergies: Review if present.
  • Family Hx/Social Hx: Complete for new patient visits; include on follow up visits if relevant
  • Physical Exam: VITALS ALWAYS, pertinent positives and negatives from your exam.
  • Data: Describe only new and relevant labs/imaging.

Assessment/Plan   

Summary Statement: Summarize the clinical situation in ~3 sentences (Who is this patient? Why are they here? What are notable findings?)
Then discuss by prioritized problem — the patient’s chief concern is always problem #1!  Always define problems to a level of certainty (dyspnea ≠ CHF, stomach pain ≠ GERD).

  • For undiagnosed problems/symptoms/findings- generate 3-5 differential diagnosis and provide clinical reasoning. List most likely, less likely, and “can not miss” diagnoses… then argue for and against each.
  • Define plan for each problem, list next steps in diagnostics or treatment
  • Health maintenance and prevention needs/plans – screening/counseling/vaccinations are reviewed as the last “problem” to every ambulatory evaluation. This is always the last problem in each discussion.
  • Define and justify follow up interval/instructions for patient prior to next visit.