SBAP in brief

Be concise - aim for 5 minutes and stay in predictable order so your others can follow

· Age/gender, type of visit?

· Chief Complaint/Concern: Main reason(s) for the visit (chief concern is often NOT what the patient says first)

· Who else is in the room and giving history? (family, hha)?

· What are your needs? are you short of time, do you have a specific learning question

· Introduce patients' baseline conditions: tailor to include only pertinent hx on followups

· HPI/ROS: in context of CC, discuss symptoms, explore pertinent pos/neg, impact on functional history, status on chronic conditions

· ROS (these are symptoms unrelated to HPI), only note positives

· Family Hx/Social Hx: Only a brief update of pertinents on follow ups

· Medications list

· Allergies: if pertinent

· Physical Exam: vital signs, pertinent pos/neg physical findings

· Data: new labs/imaging/path

With a “one liner” statement - "problem represent" key findings in the case- remember, epi, duration, key findings.

· Identify and prioritize problems to help solve in the case-chief concern is always #1. Describe problem only to the current level of certainty. Dyspnea ≠ CHF.
· For undefined symptoms or signs -discuss differentials for each, conclude w reasons for most likely diagnosis. Discuss your plan for diagnosis or treatment.
· Next list other active chronic conditions as problems to manage –review assessment thoughts, and plans (No need to list chronic conditions that are not PROBLEMS today. hyperlipidemia- continue statin, why bother)
· The last problem is health maintenance tailored to the patient's needs
· Then state a follow up/return to clinic interval, and any precaution instructions to pt.