SBAP - A Framework for Ambulatory Case Presentation

 

SBAP Ambulatory Case Presentation (also useful for notes) 

Merging SOAP with SBAR                         Nancy Chang, MD

You just saw a new patient – wow, there was a lot going on. The patient described a few new symptoms which you explored in detail. You then followed up on the status of their chronic conditions.  A ROS and psychosocial screening raised some more questions. Patient also needed refills, vaccines, and some preventive care.  How do you describe this complex event to your clinic preceptor?

The goal of case presentations is to accurately describe an encounter so our colleagues can be fully informed to collaborate in care. SBAP is a outpatient presentation framework structured to help organize raw data, walk through steps in clinical reasoning, and then conceptualize a personalized care plans. Sharing a common format for clinical communication allows colleagues to think through cases together. By understanding your diagnostic path, colleagues and supervisors can be more targetted in their assistance and guidance.  SBAP can be followed for both notes and presentations.

SBAP

S - Situation (click for examples)

Prepare your listener-Explain the context of this interaction, who and why is the patient here today (brief epi, chief concern)? What is the context of this visit-  New primary care pt? follow-up? urgent care? Preop consult? What are your needs from the listener- Are you pressed for time? Would you like them to see the pt to confirm an finding? Is there a learning question (advanced learners)?

B - Background (click for examples)

Now describing who the patient, baseline health/function, and history of present illness. Often we start with prioritized listing of of relevant prior conditions (pmhx).  This helps to set the context for the CC and HPI that follows. Sochx/Family hx/medications/allergies are also reviewed.  Physical exam and testing results then follow. (Background =SO part of SOAP)

A - Assessment (click for examples)

A case summary statement now condenses key data collected into a "one liner". The one liner is your "problem representation", it is a platform to highlight defining case features are pivotal to our  decision making.  A well written one liner, is informative, concise, and can help quickly get others up to speed. 3 things must be included:

  • Epidemiology (who is the pt and what risks factors do they have, as it relates to the cc)
  • Duration (how long is the problem going on?)
  • Syndrome (key pertinents from history, exam, or test data) 

That's it, just2-3 sentences summarizing key facts.  Do not debate differentials in the one liner as it is only a summary of  the key pieces of the puzzle in the encounter (problem representation). Keep it neutral and avoid turning it into a closing argument for a favored diagnosis, as we may throw out important facts that don't fit

P- Problem Identification  (click for example)

Identify key problems we need to solve on THIS visit. What barriers exist between this pt and wellness? Problem #1 is always the pt's concern. After that, prioritize problems that concern you (both acute and chronic dz).  Preventive care is always the last "problem" to consider. The differential diagnosis and plan ONLY discussed as a part of an identified problem.   A problem can be biomedical (headache, diabetes), or biopsychosocial (depression, or inability to afford  medication). To avoid early closure, you can only define each problem to the highest level of certainty at this very moment (For example "Problem #1 Dyspnea" instead of heart failure, if you are still not sure if copd have been  ruled out).

Click for a brief SBAP summary  

How to improve presentations  

  • Do look things up if you are not sure, pt safety and accuracy are far more important than performance. 
  • Do give context at the start, knowing the situation and pertinent background history helps listeners recognize key data and help you make decisions.
  • Do communicate if the patient has a lot of symptoms/concerns, simplifying the visit to share only "important" symptoms (in your eye) does not convey truly what transpired, and their needs.  "Dr. x, that was a difficult visit, pt had a lot of symptoms and concerns,  I will give a brief overview and focus on what they are most concerned about on this 1st visit"
  • Assessment before Plans- Problem represent (with a one liner) then identify problem(s), and then differentials for the problem. Diagnostic or therapeutic plan comes after weighing your options.
  • Be succinct, aim to speak for 5 minutes (longer for complex pts). Know that TMI can overwhelm, listeners may tune out or miss key details, therefore become less helpful.
    •  Avoid redundancy like excess use of "pt reports", "pt says", "he told me".  Or having the same situation line as your 1st HPI line 
    • Avoid editorializing “She said the pain was 10/10 but I am not sure if I believe her, she looks totally fine walking”. 
    • Curate the patient's epi in the introduction line carefully (at start of Background). Elderly or complex patients have long lists of medical conditions. If we read them all, we may lose our listeners at the setart.   Highlight what's active and pertinent to this current presentation.
    • Learn to use clinical terminology and semantic qualifiers,  Synthesized concepts help clinical listeners think faster.  “patient tells me that for many years he always feels short of breath after he walks from his house on 172nd to beyond the church on 177thstreet” = “Pt experiences chronic dyspnea when ambulating more than 5 blocks”. 
    • ps- what are the role of words like "endorse"? Feels like "pt suffers from chronic LBP" is more vividly understood than "pt endorses chronic LBP"