words to describe patient presentation

Brainy Behavior

Psychology, neuroscience, and neurology

Patient Presentation and Mood States

When writing or talking about medical patients or therapy clients, it is helpful to describe their presentation. You cover things such as appearance and grooming, mood, openness, language, and thought process. How a client looks can reveal a lot about their lives, stressors, and their overall cognitive functioning. How open they are with you as a doctor or therapist is also important to note. Sometimes people are reticent to talk about themselves (which is understandable) and distrustful in general. Some people also don’t know how to talk about themselves, so they don’t.

The language people use also reveals their underlying cognitive functioning. Tangential language, disjointed speech, and slowed speech, for example can mean different things – a thought disorder, depression, acquired brain injury, and so forth. Related to language is a person’s thought process; this is apparent from their language but also in how they describe their problems or their lives.

When discussing mood, there are three general terms doctors use. The first is euphoric – extremely happy. Sometimes it is appropriate for people to exhibit this emotion but it can also be a sign of mania, especially if the positive mood was not seemingly triggered by anything. The next term for a mood state is euthymic , meaning normal, slightly positive mood. This is the mood that most people exhibit most of the time. It is neither positive nor negative (although often interpreted as having a slight positive lean). The last descriptor for mood is dysthymic , which means depressed or having negative affect.

Using these labels when describing patients provides a common, concise set of terms. It is, however, usually better to describe behaviors than just give a label. This means when writing about a patient or client, a report might state, “[The patient] presented as dysthymic, not smiling, becoming tearful at times….” Labels are concise, descriptions are precise.

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Tools for the Patient Presentation

The formal patient presentation.

• Posing the Clinical Question
• Searching the Medical Literature for EBM

Sources & Further Reading

First Aid for the Wards

Lingard L, Haber RJ.  Teaching and learning communications in medicine: a rhetorical approach .  Academic Medicine. 74(5):507-510 1999 May.

Lingard L, Haber RJ.  What do we mean by "relevance"? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format . Academic Medicine. 74(10):S124-S127.

The Oral Presentation (A Practical Guide to Clinical Medicine, UCSD School of Medicine)  http://meded.ucsd.edu/clinicalmed/oral.htm

"Classically, the formal oral presentation is given in 7 minutes or less. Although it follows the same format as a written report, it is not simply regurgitation. A great presentation requires style as much as substance; your delivery must be succinct and smooth. No time should be wasted on superfluous information; one can read about such matters later in your admit note. Ideally, your presentation should be formulated so that your audience can anticipate your assessment and plan; that is, each piece of information should clue the listener into your thinking process and your most likely diagnosis."  [ Le, et al, p. 15 ]

Types of Patient Presentations

New Patient

New patients get the traditional H&P with assessment and plan.  Give the chief complaint and a brief and pertinent HPI.  Next give important PMH, PSH, etc.  The ROS is often left out, as anything important was in the HPI.  The PE is reviewed.  Only give pertinent positives and negatives.  The assessment and plan should include what you think is wrong and, briefly, why.  Then, state what you plan to do for the patient, including labs.  Be sure to know why things are being done: you will be asked.

The follow-up presentation differs from the presentation of a new patient.  It is an abridged presentation, perhaps referencing major patient issues that have been previously presented, but focusing on new information about these issues and/or what has changed. Give the patient’s name, age, date of admission, briefly review the present illness, physical examination and admitting diagnosis.  Then report any new finding, laboratory tests, diagnostic procedures and changes in medications.

The attending physician will ask the patient’s permission to have the medical student present their case.  After making the proper introductions the attending will let the patient know they may offer input or ask questions at any point.  When presenting at bedside the student should try to involve the patient.

Preparing for the Presentation

There are four things you must consider before you do your oral presentation

• Occasion (setting and circumstances)

Ask yourself what do you want the presentation to do

• Present a new patient to your preceptor : the amount of detail will be determined by your preceptor.  It is also likely to reflect your development and experience, with less detail being required as you progress.
• Present your patient at working or teaching rounds : the amount of detail will be determined by the customs of the group. The focus of the presentation will be influenced by the learning objectives of working responsibilities of the group.
• Request a consultant’s advice on a clinical problem : the presentation will be focused on the clinical question being posed to the consultant.
• Persuade others about a diagnosis and plan : a shorter presentation which highlights the pertinent positives and negatives that are germane to the diagnosis and/or plan being suggested.
• Enlist cooperation required for patient care : a short presentation focusing on the impact your audience can have in addressing the patient’s issues.

Preparation

• Patient evaluation : history, physical examination, review of tests, studies, procedures, and consultants’ recommendations.
• Selected reading : reference texts; to build a foundational understanding.
• Literature search : for further elucidation of any key references from selected reading, and to bring your understanding up to date, since reference text information is typically three to seven years old.
• Write-up : for oral presentation, just succinct notes to serve as a reminder or reference, since you’re not going to be reading your presentation.

Knowledge (Be prepared to answer questions about the following)

• Pathophysiology
• Complications
• Differential diagnosis
• Course of conditions
• Diagnostic tests
• Medications
• Essential Evidence Plus

Template for Oral Presentations

Chief Complaint (CC)

The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant.  If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.  For ongoing care, give a one sentence recap of the history.

History of Present Illness (HPI)

This will be very similar to your written HPI. Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically.  Cover one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives. Items from the ROS that are unrelated to the present problem may be mentioned in passing unless you are doing a very formal presentation. When you do your first patient presentation you may be expected to go into detail.  For ongoing care, present any new complaints.

Review of Systems (ROS)

Most of the ROS is incorporated at the end of the HPI. Items that are unrelated to the present problem may be briefly mentioned.  For ongoing care, present only if new complaints.  

Past Medical History (PMH)

Discuss other past medical history that bears directly on the current medical problem.  For ongoing care, have the information available to respond to questions.

Past Surgical History

Provide names of procedures, approximate dates, indications, any relevant findings or complications, and pathology reports, if applicable.  For ongoing care, have the information available to respond to questions.

Allergies/Medications

Present all current medications along with dosage, route and frequency. For the follow-up presentation just give any changes in medication.  For ongoing care, note any changes.

Smoking and Alcohol (and any other substance abuse)

Note frequency and duration. For ongoing care, have the information available to respond to questions.

Social/Work History

Home, environment, work status and sexual history.  For ongoing care, have the information available to respond to questions.

Family History Note particular family history of genetically based diseases.  For ongoing care, have the information available to respond to questions.

Physical Exam/Labs/Other Tests

Include all significant abnormal findings and any normal findings that contribute to the diagnosis. Give a brief, general description of the patient including physical appearance. Then describe vital signs touching on each major system. Try to find out in advance how thorough you need to be for your presentation. There are times when you will be expected to give more detail on each physical finding, labs and other test results.  For ongoing care, mention only further positive findings and relevant negative findings.

Assessment and Plan

Give a summary of the important aspects of the history, physical exam and formulate the differential diagnosis. Make sure to read up on the patient’s case by doing a search of the literature. 

• Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient.
• Keep your presentation lively.
• Do not read the presentation!
• Expect your listeners to ask questions.
• Follow the order of the written case report.
• Keep in mind the limitation of your listeners.
• Beware of jumping back and forth between descriptions of separate problems.
• Use the presentation to build your case.
• Your reasoning process should help the listener consider a differential diagnosis.
• Present the patient as well as the illness .
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How To Present a Patient: A Step-To-Step Guide

Last Updated on June 24, 2022 by Laura Turner

Updated and verified by Dr. Lee Burnett on March 19, 2022.

The ability to deliver oral case presentations is a core skill for any physician. Effective oral case presentations help facilitate information transfer among physicians and are essential to delivering quality patient care. Oral case presentations are also a key component of how medical students and residents are assessed during their training.

At its core, an oral case presentation functions as an argument. It is the presenter’s job to share the pertinent facts of a patient’s case with the other members of the medical care team and establish a clear diagnosis and treatment plan. Thus, the presenter should include details to support the proposed diagnosis, argue against alternative diagnoses, and exclude extraneous information. While this task may seem daunting at first, with practice, it will become easier. That said, if you are unsure if a particular detail is important to your patient’s case, it is probably best to be safe and include it.

Now, let’s go over how to present a case. While I will focus on internal medicine inpatients, the following framework can be applied to patients in any setting with slight modifications.

Oral case presentations are generally made to a medical care team, which can be composed of medical and pharmacy students, residents, pharmacists, medical attendings, and others. As the presenter, you should strive to deliver an interesting presentation that keeps your team members engaged. Here are a few things to keep in mind:

• Be confident: Speak clearly at the loudest volume appropriate to protect patient privacy, vary your tone to emphasize the most important details, and maintain eye contact with members of your team.
• Don’t fidget : Stand up straight and avoid unnecessary, distracting movements.
• Use your notes : You may glance at your notes from time to time while presenting. However, while there is no need to memorize your presentation, there is no better way to lose your team’s attention than to read your notes to them.
• Be honest: Given the importance of presentations in guiding medical care, never guess or report false information to the team. If you are unsure about a particular detail, say so.

The length of your presentation will depend on various factors, including the complexity of your patient, your audience, and your specialty. I have found that new internal medicine inpatients generally take 5-10 minutes to present. Internal medicine clerkship directors seem to agree. In a 2009 survey , they reported a range of 2-20 minutes for the ideal length of student inpatient presentations, with a median of 7 minutes.

While delivering oral case presentations is a core skill for trainees, and there have been attempts to standardize the format , expectations still vary among attending physicians. This can be a frustrating experience for trainees, and I would recommend that you clarify your attending’s expectations at the beginning of each new rotation. However, I have found that these differences are often stylistic, and content expectations are generally quite similar. Thus, developing a familiarity with the core elements of a strong oral case presentation is essential.

How to Present a Patient

You should begin every oral presentation with a brief one-liner that contains the patient’s name, age, relevant past medical history, and chief complaint. Remember that the chief complaint is why the patient sought medical care in his or her own words. An example of an effective opening is as follows: “Ms. X is a 78-year-old female with a past medical history of chronic obstructive pulmonary disease who presents to the hospital after she felt short of breath at home.”

Following the opener, elaborate on why the patient sought medical care. Describe the events that preceded the patient’s presentation in chronological order. A useful mnemonic to use when deciding what to report is OPQRST , which includes: • The Onset of the patient’s symptoms • Any Palliative or Provoking factors that make the symptoms better or worse, respectively • The Quality of his or her symptoms (how he or she describes them) • The Region of the body where the patient is experiencing his or her symptoms and (if the symptom is pain) whether the patient’s pain Radiates to another location or is well-localized • The Severity of the symptoms and any other associated Symptoms • The Time course of the symptoms (how they have changed over time and whether the patient has experienced them before) Additionally, include any other details here that may support your final diagnosis or rule out alternative diagnoses. For example, if you are concerned about a pulmonary embolism and your patient recently completed a long-distance flight, that would be worth mentioning.

The review of systems is sometimes included in the history of present illness, but it may also be separated. Given the potential breadth of the review of systems (a comprehensive list of questions that may be asked can be found here ), when presenting, only report information that is relevant to your patient’s condition.

The past medical history comes next. This should include the following information: • The patient’s medical conditions, including any that were not highlighted in the opener • Any past surgeries the patient has had and when they were performed • The timing of and reasons for past hospitalizations • Any current medications, including dosages and frequency of administration

The next section should detail the patient’s relevant family history. This should include: • Any relevant conditions that run in the patient’s family, with an emphasis on first-degree relatives

After the family history comes the social history. This section should include information about the patient’s: • Living situation • Occupation • Alcohol and tobacco use • Other substance use You may also include relevant details about the patient’s education level, recent travel history, history of animal and occupational exposures, and religious beliefs. For example, it would be worth mentioning that your anemic patient is a Jehovah’s Witness to guide medical decisions regarding blood transfusions.

Once you have finished reporting the patient’s history, you should transition to the physical exam. You should begin by reporting the patient’s vital signs, which includes the patient’s: • Temperature • Heart rate • Blood pressure • Respiratory rate • Oxygen saturation (if the patient is using supplemental oxygen, this should also be reported) Next, you should discuss the findings of your physical exam. At the minimum, this should include: • Your general impressions of the patient, including whether he or she appears “sick” or not • The results of your: • Head and neck exam • Eye exam • Respiratory exam • Cardiac exam • Abdominal exam • Extremity exam • Neurological exam Additional relevant physical examination findings may be included, as well. Quick note: resist the urge to report an exam as being “normal.” Instead, report your findings. For example, for a normal abdominal exam, you could report that “the patient’s abdomen is soft, non-tender, and non-distended, with normoactive bowel sounds.”

This section includes the results of any relevant laboratory testing, imaging, or other diagnostics that were obtained. You do not have to report the results of every test that was ordered. Before presenting, consider which results will further support your proposed diagnosis and exclude alternatives.

The emergency department (ED) course is classically reported towards the end of the presentation. However, different attendings may prefer to hear the ED course earlier, usually following the history of present illness. When unsure, report the ED course after the results of diagnostic testing. Be sure to include initial ED vital signs and any administered treatments.

You should conclude your presentation with the assessment and plan. This is the most important part of your presentation and allows you to show your team how much you really know. You should include: • A brief summary (1-2 lines) of the patient, the reason for admission, and your likely diagnosis. This should also include information regarding the patient’s clinical stability. While it can be similar to your opener, it should not be identical. An example could be: “Ms. X is a 78-year-old female with a past medical history of chronic obstructive pulmonary disease who presents with shortness of breath in the setting of an upper respiratory tract infection who is now stable on two liters of supplemental oxygen delivered via nasal cannula. Her symptoms are thought to be secondary to an acute exacerbation of chronic obstructive pulmonary disease.” • A differential diagnosis . For students, this should consist of 3-5 potential diagnoses. You should explain why you think each diagnosis is or is not the final diagnosis. Be sure to rule out potentially life-threatening conditions (unless you think your patient has one). For our fictional patient, Ms. X, for example, you could explain why you think she does not have a pulmonary embolism or acute coronary syndrome. For more advanced trainees, the differential can be more limited in scope. • Your plan . On regular inpatient floors, this should include a list of the patient’s medical problems, ordered by acuity, followed by your proposed plan for each. After going through each active medical problem, be sure to mention your choice for the patient’s diet and deep vein thrombosis prophylaxis, the patient’s stated code status, and the patient’s disposition (whether you think they need to remain in the hospital). In intensive care units, you can organize the patient’s medical problems by organ system to ensure that no stone is left unturned (if there are no active issues for an organ system, you may say so).

Presenting Patients Who Have Been in the Hospital for Multiple Days

After the initial presentation, subsequent presentations can be delivered via SOAP note format as follows:

• The  Subjective  section includes details about any significant overnight events and any new complaints the patient has.
• In the  Objective  section, report your physical exam (focus on any changes since you last examined the patient) and any significant new laboratory, imaging, or other diagnostic results.
• The  Assessment  and  Plan  are typically delivered as above. For the initial patient complaint, you do not have to restate your differential diagnosis if the diagnosis is known. For new complaints, however, you should create another differential and argue for or against each diagnosis. Be sure to update your plan every day.

Presenting Patients in Different Specialties

Before you present a patient, consider your audience. Every specialty presents patients differently. In general, surgical and OB/GYN presentations tend to be much quicker (2-3 minutes), while pediatric and family medicine presentations tend to be similar in length to internal medicine presentations. Tailor your presentations accordingly.

Presenting Patients in Outpatient Settings

Outpatients may be presented similarly to inpatients. Your presentation’s focus, however, should align with your outpatient clinic’s specialty. For example, if you are working at a cardiology clinic, your presentation should be focused on your patient’s cardiac complaints.

If your patient is returning for a follow-up visit and does not have a stated chief complaint, you should say so. You may replace the history of present illness with any relevant interval history since his or her last visit.

And that’s it! Delivering oral case presentations is challenging at first, so remember to practice. In time, you will become proficient in this essential medical skill. Good luck!

Kunal Sindhu, MD, is an assistant professor in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai and New York Proton Center. Dr. Sindhu specializes in treating cancers of the head, neck, and central nervous system.

2 thoughts on “How To Present a Patient: A Step-To-Step Guide”

To clarify, it should take 5-10 minutes to present (just one) new internal medicine inpatient? Or if the student had 4 patients to work up, it should take 10 minutes to present all 4 patients to the preceptor?

Good question. That’s per case, but with time you’ll become faster.

Comments are closed.

The Ultimate Patient Case Presentation Template for Med Students

• April 6, 2024
• Reviewed by: Amy Rontal, MD

Knowing how to deliver a patient presentation is one of the most important skills to learn on your journey to becoming a physician. After all, when you’re on a medical team, you’ll need to convey all the critical information about a patient in an organized manner without any gaps in knowledge transfer.

One big caveat: opinions about the correct way to present a patient are highly personal and everyone is slightly different. Additionally, there’s a lot of variation in presentations across specialties, and even for ICU vs floor patients.

My goal with this blog is to give you the most complete version of a patient presentation, so you can tailor your presentations to the preferences of your attending and team. So, think of what follows as a model for presenting any general patient.

Here’s a breakdown of what goes into the typical patient presentation.

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7 Ingredients for a Patient Case Presentation Template

1. the one-liner.

The one-liner is a succinct sentence that primes your listeners to the patient.

A typical format is: “[Patient name] is a [age] year-old [gender] with past medical history of [X] presenting with [Y].

2. The Chief Complaint

This is a very brief statement of the patient’s complaint in their own words. A common pitfall is when medical students say that the patient had a chief complaint of some medical condition (like cholecystitis) and the attending asks if the patient really used that word!

An example might be, “Patient has chief complaint of difficulty breathing while walking.”

3. History of Present Illness (HPI)

The goal of the HPI is to illustrate the story of the patient’s complaint. I remember when I first began medical school, I had a lot of trouble determining what was relevant and ended up giving a lot of extra details. Don’t worry if you have the same issue. With time, you’ll learn which details are important. 

The OPQRST Framework

In the beginning of your clinical experience, a helpful framework to use is OPQRST:

Describe when the issue started, and if it occurs during certain environmental or personal exposures.

P rovocative

Report if there are any factors that make the pain better or worse. These can be broad, like noting their shortness of breath worsened when lying flat, or their symptoms resolved during rest. 

Relay how the patient describes their pain or associated symptoms. For example, does the patient have a burning versus a pressure sensation? Are they feeling weakness, stiffness, or pain?

R egion/Location

Indicate where the pain is located and if it radiates anywhere.

Talk about how bad the pain is for the patient. Typically, a 0-10 pain scale is useful to provide some objective measure.

Discuss how long the pain lasts and how often it occurs.

A Case Study

While the OPQRST framework is great when starting out, it can be limiting. Let’s take an example where the patient is not experiencing pain and comes in with altered mental status along with diffuse jaundice of the skin and a history of chronic liver disease. You will find that certain sections of OPQRST do not apply. In this event, the HPI is still a story, but with a different framework. Try to go in chronological order. Include relevant details like if there have been any changes in medications, diet, or bowel movements.

Pertinent Positive and Negative Symptoms

Regardless of the framework you use, the name of the game is pertinent positive and negative symptoms the patient is experiencing. I’d like to highlight the word “pertinent.” It’s less likely the patient’s chronic osteoarthritis and its management is related to their new onset shortness of breath, but it’s still important for knowing the patient’s complete medical picture. A better place to mention these details would be in the “Past Medical History” section, and reserve the HPI portion for more pertinent history. As you become exposed to more illness scripts, experience will teach you which parts of the history are most helpful to state. Also, as you spend more time on the wards, you will pick up on which questions are relevant and important to ask during the patient interview.   By painting a clear picture with pertinent positives and negatives during your presentation, the history will guide what may be higher or lower on the differential diagnosis. Some other important components to add are the patient’s additional past medical/surgical history, family history, social history, medications, allergies, and immunizations.

The HEADSSS Method

Particularly, the social history is an important time to describe the patient as a complete person and understand how their life story may affect their present condition. One way of organizing the social history is the HEADSSS method: – H ome living situation and relationships – E ducation and employment – A ctivities and hobbies – D rug use (alcohol, tobacco, cocaine, etc.) Note frequency of use, and if applicable, be sure to add which types of alcohol consumption (like beer versus hard liquor) and forms of drug use. – S exual history (partners, STI history, pregnancy plans) – S uicidality and depression – S piritual and religious history   Again, there’s a lot of variation in presenting social history, so just follow the lead of your team. For example, it’s not always necessary/relevant to obtain a sexual history, so use your judgment of the situation.

4. Review of Symptoms

Oftentimes, most elements of this section are embedded within the HPI. If there are any additional symptoms not mentioned in the HPI, it’s appropriate to state them here.

5. Objective

Vital signs.

Some attendings love to hear all five vital signs: temperature, blood pressure (mean arterial pressure if applicable), heart rate, respiratory rate, and oxygen saturation. Others are happy with “afebrile and vital signs stable.” Just find out their preference and stick to that. 

Physical Exam  

This is one of the most important parts of the patient presentation for any specialty. It paints a picture of how the patient looks and can guide acute management like in the case of a rigid abdomen. As discussed in the HPI section, typically you should report pertinent positives and negatives. When you’re starting out, your attending and team may prefer for you to report all findings as part of your learning. For example, pulmonary exam findings can be reported as: “Regular chest appearance. No abnormalities on palpation. Lungs resonant to percussion. Clear to auscultation bilaterally without crackles, rhonchi, or wheezing.” Typically, you want to report the physical exams in a head to toe format: General Appearance, Mental Status, Neurologic, Eyes/Ears/Nose/Mouth/Neck, Cardiovascular, Pulmonary, Breast, Abdominal, Genitourinary, Musculoskeletal, and Skin. Depending on the situation, additional exams can be incorporated as applicable.

Now comes reporting pertinent positive and negative labs. Several labs are often drawn upon admission. It’s easy to fall into the trap of reading off all the labs and losing everyone’s attention. Here are some pieces of advice: 

You normally can’t go wrong sticking to abnormal lab values. 

One qualification is that for a patient with concern for acute coronary syndrome, reporting a normal troponin is essential. Also, stating the normalization of previously abnormal lab values like liver enzymes is important.

Demonstrate trends in lab values.

A lab value is just a single point in time and does not paint the full picture. For example, a hemoglobin of 10g/dL in a patient at 15g/dL the previous day is a lot more concerning than a patient who has been stable at 10g/dL for a week.

Try to avoid editorializing in this section.

Save your analysis of the labs for the assessment section. Again, this can be a point of personal preference. In my experience, the team typically wants the raw objective data in this section. This is also a good place to state the ins and outs of your patient (if applicable). In some patients, these metrics are strictly recorded and are typically reported as total fluid in and out over the past day followed by the net fluid balance. For example, “1L in, 2L out, net -1L over the past 24 hours.”

6. Diagnostics/Imaging

Next, you’ll want to review any important diagnostic tests and imaging. For example, describe how the EKG and echo look in a patient presenting with chest pain or the abdominal CT scan in a patient with right lower quadrant abdominal pain. Try to provide your own interpretation to develop your skills and then include the final impression. Also, report if a diagnostic test is still pending.

7. Assessment/Plan

This is the fun part where you get to use your critical thinking (aka doctor) skills! For the scope of this blog, we’ll review a problem-based plan. It’s helpful to begin with a summary statement that incorporates the one-liner, presenting issue(s)/diagnosis(es), and patient stability. Then, go through all the problems relevant to the admission. You can impress your audience by casting a wide differential diagnosis and going through the elements of your patient presentation that support one diagnosis over another.  Following your assessment, try to suggest a management plan. In a patient with congestive heart failure exacerbation, initiating a diuresis regimen and measuring strict ins/outs are good starting points. You may even suggest a follow-up on their latest ejection fraction with an echo and check if they’re on guideline-directed medical therapy. Again, with more time on the clinical wards you’ll start to pick up on what management plan to suggest. One pointer is to talk about all relevant problems, not just the presenting issue. For example, a patient with diabetes may need to be put on a sliding scale insulin regimen or another patient may require physical/occupational therapy. Just try to stay organized and be comprehensive.

A Note About Patient Presentation Skills

When you’re doing your first patient presentations, it’s common to feel nervous. There may be a lot of “uhs” and “ums.”

Here’s the good news: you don’t have to be perfect! You just need to make a good faith attempt and keep on going with the presentation.

With time, your confidence will build. Practice your fluency in the mirror when you have a chance. No one was born knowing medicine and everyone has gone through the same stages of learning you are!

Practice your presentation a couple times before you present to the team if you have time. Pull a resident aside if they have the bandwidth to make sure you have all the information you need. 

One big piece of advice: NEVER LIE. If you don’t know a specific detail, it’s okay to say, “I’m not sure, but I can look that up.” Someone on your team can usually retrieve the information while you continue on with your presentation.

Example Patient Case Presentation Template

Here’s a blank patient case presentation template that may come in handy. You can adapt it to best fit your needs.   One-Liner:   Chief Complaint:   History of Present Illness:   Past Medical History: Past Surgical History: Family History: Social History: Medications: Allergies: Immunizations:   ROS:   Objective:   Vital Signs : Temp ___ BP ___ /___ HR ___ RR ___ O2 sat ___   Physical Exam:

General Appearance:

Mental Status:

Neurological:

Eyes, Ears, Nose, Mouth, and Neck:

Cardiovascular:

Genitourinary:

Musculoskeletal:

Most Recent Labs:

Previous Labs:

Diagnostics/Imaging:

Impression/Interpretation:

Assessment/Plan:

One-line summary:

#Problem 1:

Assessment:

#Problem 2:

Final Thoughts on Patient Presentations

I hope this post demystified the patient presentation for you. Be sure to stay organized in your delivery and be flexible with the specifications your team may provide.   Something I’d like to highlight is that you may need to tailor the presentation to the specialty you’re on. For example, on OB/GYN, it’s important to include a pregnancy history. Nonetheless, the aforementioned template should set you up for success from a broad overview perspective.   Stay tuned for my next post on how to give an ICU patient presentation. And if you’d like me to address any other topics in a blog, write to me at [email protected] ! Looking for more (free!) content to help you through clinical rotations? Check out these other posts from Blueprint tutors on the Med School blog:

• How I Balanced My Clinical Rotations with Shelf Exam Studying
• How (and Why) to Use a Qbank to Prepare for USMLE Step 2
• How to Study For Shelf Exams: A Tutor’s Guide

About the Author

Hailing from Phoenix, AZ, Neelesh is an enthusiastic, cheerful, and patient tutor. He is a fourth year medical student at the Keck School of Medicine of the University of Southern California and serves as president for the Class of 2024. He is applying to surgery programs for residency. He also graduated as valedictorian of his high school and the USC Viterbi School of Engineering, obtaining a B.S. in Biomedical Engineering in 2020. He discovered his penchant for teaching when he began tutoring his friends for the SAT and ACT in the summer of 2015 out of his living room. Outside of the academic sphere, Neelesh enjoys surfing at San Onofre Beach and hiking in the Santa Monica Mountains. Twitter: @NeeleshBagrodia LinkedIn: http://www.linkedin.com/in/neelesh-bagrodia

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Overview and General Information about Oral Presentation

• Daily Presentations During Work Rounds
• The New Patient Presentation
• The Holdover Admission Presentation
• Outpatient Clinic Presentations
• The structure of presentations varies from service to service (e.g. medicine vs. surgery), amongst subspecialties, and between environments (inpatient vs. outpatient). Applying the correct style to the right setting requires that the presenter seek guidance from the listeners at the outset.
• Time available for presenting is rather short, which makes the experience more stressful.
• Individual supervisors (residents, faculty) often have their own (sometimes quirky) preferences regarding presentation styles, adding another layer of variability that the presenter has to manage.
• Students are evaluated/judged on the way in which they present, with faculty using this as one way of gauging a student’s clinical knowledge.
• Done well, presentations promote efficient, excellent care. Done poorly, they promote tedium, low morale, and inefficiency.

General Tips:

• Practice, Practice, Practice! Do this on your own, with colleagues, and/or with anyone who will listen (and offer helpful commentary) before you actually present in front of other clinicians. Speaking "on-the-fly" is difficult, as rapidly organizing and delivering information in a clear and concise fashion is not a naturally occurring skill.
• Immediately following your presentations, seek feedback from your listeners. Ask for specifics about what was done well and what could have been done better – always with an eye towards gaining information that you can apply to improve your performance the next time.
• Listen to presentations that are done well – ask yourself, “Why was it good?” Then try to incorporate those elements into your own presentations.
• Listen to presentations that go poorly – identify the specific things that made it ineffective and avoid those pitfalls when you present.
• Effective presentations require that you have thought through the case beforehand and understand the rationale for your conclusions and plan. This, in turn, requires that you have a good grasp of physiology, pathology, clinical reasoning and decision-making - pushing you to read, pay attention, and in general acquire more knowledge.
• Think about the clinical situation in which you are presenting so that you can provide a summary that is consistent with the expectations of your audience. Work rounds, for example, are clearly different from conferences and therefore mandate a different style of presentation.
• Presentations are the way in which we tell medical stories to one another. When you present, ask yourself if you’ve described the story in an accurate way. Will the listener be able to “see” the patient the same way that you do? Can they come to the correct conclusions? If not, re-calibrate.
• It's O.K. to use notes, though the oral presentation should not simply be reduced to reading the admission note – rather, it requires appropriate editing/shortening.
• In general, try to give your presentations on a particular service using the same order and style for each patient, every day. Following a specific format makes it easier for the listener to follow, as they know what’s coming and when they can expect to hear particular information. Additionally, following a standardized approach makes it easier for you to stay organized, develop a rhythm, and lessens the chance that you’ll omit elements.

Specific types of presentations

There are a number of common presentation-types, each with its own goals and formats. These include:

• Daily presentations during work rounds for patients known to a service.
• Newly admitted patients, where you were the clinician that performed the H&P.
• Newly admitted patients that were “handed off” to the team in the morning, such that the H&P was performed by others.
• Outpatient clinic presentations, covering several common situations.

Key elements of each presentation type are described below. Examples of how these would be applied to most situations are provided in italics. The formats are typical of presentations done for internal medicine services and clinics.

Note that there is an acceptable range of how oral presentations can be delivered. Ultimately, your goal is to tell the correct story, in a reasonable amount of time, so that the right care can be delivered. Nuances in the order of presentation, what to include, what to omit, etc. are relatively small points. Don’t let the pursuit of these elements distract you or create undue anxiety.

Daily presentations during work rounds of patients that you’re following:

• Organize the presenter (forces you to think things through)
• Inform the listener(s) of 24 hour events and plan moving forward
• Promote focused discussion amongst your listeners and supervisors
• Opportunity to reassess plan, adjust as indicated
• Demonstrate your knowledge and engagement in the care of the patient
• Rapid (5 min) presentation of the key facts

Key features of presentation:

• Opening one liner: Describe who the patient is, number of days in hospital, and their main clinical issue(s).
• 24-hour events: Highlighting changes in clinical status, procedures, consults, etc.
• Subjective sense from the patient about how they’re feeling, vital signs (ranges), and key physical exam findings (highlighting changes)
• Relevant labs (highlighting changes) and imaging
• Assessment and Plan : Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.

Example of a daily presentation for a patient known to a team:

• Opening one liner: This is Mr. Smith, a 65 year old man, Hospital Day #3, being treated for right leg cellulitis
• MRI of the leg, negative for osteomyelitis
• Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate amount of pus
• Patient appears well, states leg is feeling better, less painful
• T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room Air
• Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
• Right lower extremity redness now limited to calf, well within inked lines – improved compared with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No evidence of fluctuance or undrained infection.
• Creatinine .8, down from 1.5 yesterday
• WBC 8.7, down from 14
• Blood cultures from admission still negative
• Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
• MRI lower extremity as noted above – negative for osteomyelitis
• Continue Vancomycin for today
• Ortho to reassess I&D site, though looks good
• Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO Dicloxacillin
• Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to restart
• Add back amlodipine 5mg/d today
• Hep lock IV as no need for more IVF
• Continue to hold ace-I as above
• Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this afternoon.
• Set up follow-up with PMD to reassess wound and cellulitis within 1 week

The Brand New Patient (admitted by you)

• Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis.
• Present a thoughtful assessment
• Present diagnostic and therapeutic plans
• Provide opportunities for senior listeners to intervene and offer input
• Chief concern: Reason why patient presented to hospital (symptom/event and key past history in one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes, hypertension, etc.) if these elements might contribute to the reason for admission.
• The history is presented highlighting the relevant events in chronological order.
• 7 days ago, the patient began to notice vague shortness of breath.
• 5 days ago, the breathlessness worsened and they developed a cough productive of green sputum.
• 3 days ago his short of breath worsened to the point where he was winded after walking up a flight of stairs, accompanied by a vague right sided chest pain that was more pronounced with inspiration.
• Enough historical information has to be provided so that the listener can understand the reasons that lead to admission and be able to draw appropriate clinical conclusions.
• Past history that helps to shed light on the current presentation are included towards the end of the HPI and not presented later as “PMH.” This is because knowing this “past” history is actually critical to understanding the current complaint. For example, past cardiac catheterization findings and/or interventions should be presented during the HPI for a patient presenting with chest pain.
• Where relevant, the patient's baseline functional status is described, allowing the listener to understand the degree of impairment caused by the acute medical problem(s).
• It should be explicitly stated if a patient is a poor historian, confused or simply unaware of all the details related to their illness. Historical information obtained from family, friends, etc. should be described as such.
• Review of Systems (ROS): Pertinent positive and negative findings discovered during a review of systems are generally incorporated at the end of the HPI. The listener needs this information to help them put the story in appropriate perspective. Any positive responses to a more inclusive ROS that covers all of the other various organ systems are then noted. If the ROS is completely negative, it is generally acceptable to simply state, "ROS negative.”
• Other Past Medical and Surgical History (PMH/PSH): Past history that relates to the issues that lead to admission are typically mentioned in the HPI and do not have to be repeated here. That said, selective redundancy (i.e. if it’s really important) is OK. Other PMH/PSH are presented here if relevant to the current issues and/or likely to affect the patient’s hospitalization in some way. Unrelated PMH and PSH can be omitted (e.g. if the patient had their gall bladder removed 10y ago and this has no bearing on the admission, then it would be appropriate to leave it out). If the listener really wants to know peripheral details, they can read the admission note, ask the patient themselves, or inquire at the end of the presentation.
• Medications and Allergies: Typically all meds are described, as there’s high potential for adverse reactions or drug-drug interactions.
• Family History: Emphasis is placed on the identification of illnesses within the family (particularly among first degree relatives) that are known to be genetically based and therefore potentially heritable by the patient. This would include: coronary artery disease, diabetes, certain cancers and autoimmune disorders, etc. If the family history is non-contributory, it’s fine to say so.
• Social History, Habits, other → as relates to/informs the presentation or hospitalization. Includes education, work, exposures, hobbies, smoking, alcohol or other substance use/abuse.
• Sexual history if it relates to the active problems.
• Vital signs and relevant findings (or their absence) are provided. As your team develops trust in your ability to identify and report on key problems, it may become acceptable to say “Vital signs stable.”
• Note: Some listeners expect students (and other junior clinicians) to describe what they find in every organ system and will not allow the presenter to say “normal.” The only way to know what to include or omit is to ask beforehand.
• Key labs and imaging: Abnormal findings are highlighted as well as changes from baseline.
• Summary, assessment & plan(s) Presented by problem or organ systems(s), using as many or few as are relevant. Early on, it’s helpful to go through the main categories in your head as a way of making sure that you’re not missing any relevant areas. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• The assessment and plan typically concludes by mentioning appropriate prophylactic considerations (e.g. DVT prevention), code status and disposition.
• Chief Concern: Mr. H is a 50 year old male with AIDS, on HAART, with preserved CD4 count and undetectable viral load, who presents for the evaluation of fever, chills and a cough over the past 7 days.
• Until 1 week ago, he had been quite active, walking up to 2 miles a day without feeling short of breath.
• Approximately 1 week ago, he began to feel dyspneic with moderate activity.
• 3 days ago, he began to develop subjective fevers and chills along with a cough productive of red-green sputum.
• 1 day ago, he was breathless after walking up a single flight of stairs and spent most of the last 24 hours in bed.
• Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal urethritis
• Was not treated with HAART at that time due to concomitant alcohol abuse and non-adherence.
• Diagnosed and treated for PJP pneumonia 2006
• Diagnosed and treated for CMV retinitis 2007
• Became sober in 2008, at which time interested in HAART. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at the University HIV clinic.
• CD4 count 3 months ago was 400 and viral load was undetectable.
• He is a gay male, not currently sexually active. He has never used intravenous drugs.
• He has no history of asthma, COPD or chronic cardiac or pulmonary condition. No known liver disease. Hepatitis B and C negative. His current problem seems different to him then his past episode of PJP.
• Review of systems: negative for headache, photophobia, stiff neck, focal weakness, chest pain, abdominal pain, diarrhea, nausea, vomiting, urinary symptoms, leg swelling, or other complaints.
• Hypertension x 5 years, no other known vascular disease
• Gonorrhea as above
• Alcohol abuse above and now sober – no known liver disease
• No relevant surgeries
• Atripla, 1 po qd
• Omeprazole 20 mg, 1 PO, qd
• Lisinopril 20mg, qd
• Naprosyn 250 mg, 1-2, PO, BID PRN
• No allergies
• Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer.
• Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment in the city.
• Smokes 1 pack of cigarettes per day and has done so for 20 years.
• No current alcohol use. Denies any drug use.
• Sexual History as noted above; has sex exclusively with men, last partner 6 months ago.
• Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system. Breathing was labored and accessory muscles were in use. Able to speak in brief sentences, limited by shortness of breath
• Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face Mask) 95%
• HEENT: No thrush, No adenopathy
• Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base.
• Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
• Abdomen and Genital exams: normal
• Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
• Skin: no eruptions noted.
• Neurological exam: normal
• WBC 18 thousand with 10% bands;
• Normal Chem 7 and LFTs.
• Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
• Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci.
• CXR remarkable for dense right lower lobe infiltrate without effusion.
• Monitored care unit, with vigilance for clinical deterioration.
• Hypertension: given significant pneumonia and unclear clinical direction, will hold lisinopril. If BP > 180 and or if clear not developing sepsis, will consider restarting.
• Low molecular weight heparin
• Code Status: Wishes to be full code full care, including intubation and ICU stay if necessary. Has good quality of life and hopes to return to that functional level. Wishes to reconsider if situation ever becomes hopeless. Older brother Tom is surrogate decision maker if the patient can’t speak for himself. Tom lives in San Diego and we have his contact info. He is aware that patient is in the hospital and plans on visiting later today or tomorrow.
• Expected duration of hospitalization unclear – will know more based on response to treatment over next 24 hours.

The holdover admission (presenting data that was generated by other physicians)

• Handoff admissions are very common and present unique challenges
• Understand the reasons why the patient was admitted
• Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans
• Does the data support the working diagnosis?
• Do the planned tests and consults make sense?
• What else should be considered (both diagnostically and therapeutically)?
• This process requires that the accepting team thoughtfully review their colleagues efforts with a critical eye – which is not disrespectful but rather constitutes one of the main jobs of the accepting team and is a cornerstone of good care *Note: At some point during the day (likely not during rounds), the team will need to verify all of the data directly with the patient.
• 8-10 minutes
• Chief concern: Reason for admission (symptom and/or event)
• Temporally presented bullets of events leading up to the admission
• Review of systems
• Relevant PMH/PSH – historical information that might affect the patient during their hospitalization.
• Meds and Allergies
• Family and Social History – focusing on information that helps to inform the current presentation.
• Habits and exposures
• Physical exam, imaging and labs that were obtained in the Emergency Department
• Assessment and plan that were generated in the Emergency Department.
• Overnight events (i.e. what happened in the Emergency Dept. and after the patient went to their hospital room)? Responses to treatments, changes in symptoms?
• How does the patient feel this morning? Key exam findings this morning (if seen)? Morning labs (if available)?
• Assessment and Plan , with attention as to whether there needs to be any changes in the working differential or treatment plan. The broad organ system categories include (presented here head-to-toe): Neurological; Psychiatric; Cardiovascular; Pulmonary; Gastrointestinal; Renal/Genitourinary; Hematologic/Oncologic; Endocrine/Metabolic; Infectious; Tubes/lines/drains; Disposition.
• Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in by his daughter, who felt that her father was no longer able to safely take care for himself.
• 10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder.
• 1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal pain anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
• Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food.
• ROS: negative for falls, prior joint or musculoskeletal problems, fevers, chills, cough, sob, chest pain, head ache, abdominal pain, urinary or bowel symptoms, substance abuse
• Hypertension
• Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by echo 2 y ago
• Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and hypertension
• aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
• Allergies: none
• Family and Social: lives alone in a rural area of the county, in contact with children every month or so. Retired several years ago from work as truck driver. Otherwise non-contributory.
• Habits: denies alcohol or other drug use.
• Temp 98 Pulse 110 BP 100/70
• Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for evaluation of shoulder pain, but doesn’t know the name of the hospital or city
• CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
• Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal.
• CXR: normal
• EKG: sr 100; nl intervals, no acute changes
• WBC 13; hemoglobin 14
• Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
• LFTs and UA normal
• Vancomycin and Zosyn for now
• Orthopedics to see asap to aspirate shoulder for definitive diagnosis
• If aspiration is consistent with infection, will need to go to Operating Room for wash out.
• Urine electrolytes
• Follow-up on creatinine and obtain renal ultrasound if not improved
• Renal dosing of meds
• Strict Ins and Outs.
• follow exam
• obtain additional input from family to assure baseline is, in fact, normal
• Since admission (6 hours) no change in shoulder pain
• This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
• T Current 101F Pulse 100 BP 140/80
• Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
• L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain limits any active or passive range of motion to less than 10 degrees in all directions
• Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
• Continue with Vancomycin and Zosyn for now
• I already paged Orthopedics this morning, who are en route for aspiration of shoulder, fluid for gram stain, cell count, culture
• If aspirate consistent with infection, then likely to the OR
• Continue IVF at 125/h, follow I/O
• Repeat creatinine later today
• Not on any nephrotoxins, meds renaly dosed
• Continue antibiotics, evaluation for primary source as above
• Discuss with family this morning to establish baseline; possible may have underlying dementia as well
• SC Heparin for DVT prophylaxis
• Code status: full code/full care.

Outpatient-based presentations

There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in detail below.

• The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician.
• The patient who is returning to primary care for a scheduled follow-up visit.
• The patient who is presenting with an acute problem to a primary care clinic
• The specialty clinic evaluation (new or follow-up)

It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.

The Brand New Primary Care Patient

Purpose of the presentation

• Accurately review all of the patient’s history as well as any new concerns that they might have.
• Identify health related problems that need additional evaluation and/or treatment
• Provide an opportunity for senior listeners to intervene and offer input

Key features of the presentation

• If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new doctor.
• It might well include continuation of therapies and/or evaluations started elsewhere.
• If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well. Note: There may well not be a "chief complaint."
• For a new patient, this is an opportunity to highlight the main issues that might be troubling/bothering them.
• This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be discussed.
• Sometimes, there are no specific areas that the patient wishes to discuss up-front.
• Review of systems (ROS): This is typically comprehensive, covering all organ systems. If the patient is known to have certain illnesses (e.g. diabetes), then the ROS should include the search for disorders with high prevalence (e.g. vascular disease). There should also be some consideration for including questions that are epidemiologically appropriate (e.g. based on age and sex).
• Past Medical History (PMH): All known medical conditions (in particular those requiring ongoing treatment) are listed, noting their duration and time of onset. If a condition is followed by a specialist or co-managed with other clinicians, this should be noted as well. If a problem was described in detail during the “acute” history, it doesn’t have to be re-stated here.
• Past Surgical History (PSH): All surgeries, along with the year when they were performed
• Medications and allergies: All meds, including dosage, frequency and over-the-counter preparations. Allergies (and the type of reaction) should be described.
• Social: Work, hobbies, exposures.
• Sexual activity – may include type of activity, number and sex of partner(s), partner’s health.
• Smoking, Alcohol, other drug use: including quantification of consumption, duration of use.
• Family history: Focus on heritable illness amongst first degree relatives. May also include whether patient married, in a relationship, children (and their ages).
• Physical Exam: Vital signs and relevant findings (or their absence).
• Key labs and imaging if they’re available. Also when and where they were obtained.
• Summary, assessment & plan(s) presented by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic. This typically concludes with a “health care maintenance” section, which covers age, sex and risk factor appropriate vaccinations and screening tests.

The Follow-up Visit to a Primary Care Clinic

• Organize the presenter (forces you to think things through).
• Accurately review any relevant interval health care events that might have occurred since the last visit.
• Identification of new symptoms or health related issues that might need additional evaluation and/or treatment
• If the patient has no concerns, then verification that health status is stable
• Review of medications
• Provide an opportunity for listeners to intervene and offer input
• Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last visit occurred *Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may simply be returning for a visit as directed by their doctor.
• Events since the last visit: This might include emergency room visits, input from other clinicians/specialists, changes in medications, new symptoms, etc.
• Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the ROS could be rather cursory.
• PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to the listener and actionable aspects have presumably been added to the problem list (presented at the end). That said, these elements can be restated if the patient has a new symptom or issue related to a historical problem has emerged.
• MEDS : A good idea to review these at every visit.
• Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
• Lab and Imaging: The reason why these were done should be mentioned and any key findings mentioned, highlighting changes from baseline.
• Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that concern should be described.

The Focused Visit to a Primary Care Clinic

• Accurately review the historical events that lead the patient to make the appointment.
• Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or therapeutic approach to the new symptom or concern.
• Generate an appropriate assessment and plan
• Allow the listener to comment

Key features of the presentation:

• Reason for the visit
• History of Present illness: Description of the sequence of symptoms and/or events that lead to the patient’s current condition.
• Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of diagnostic possibilities that relate to the presenting problem.
• PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
• PE: Vital signs and key findings (or lack thereof)
• Labs and imaging (if done)
• Assessment and Plan: This is usually very focused and relates directly to the main presenting symptom(s) or issues.

The Specialty Clinic Visit

Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures. Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician for guidance as to what’s expected to be covered in a particular clinic environment.

• Highlight the reason(s) for the visit
• Review key data
• Provide an opportunity for the listener(s) to comment
• 5-7 minutes
• If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
• If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the last visit took place
• If it’s for an acute issue, state up front what the issue is Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic may simply be returning for a return visit as directed
• For a new patient, this highlights the main things that might be troubling/bothering the patient.
• For a specialty clinic, the history presented typically relates to the symptoms and/or events that are pertinent to that area of care.
• Review of systems , focusing on those elements relevant to that clinic. For a cardiology patient, this will highlight a vascular ROS.
• PMH/PSH that helps to inform the current presentation (e.g. past cardiac catheterization findings/interventions for a patient with chest pain) and/or is otherwise felt to be relevant to that clinic environment.
• Meds and allergies: Typically all meds are described, as there is always the potential for adverse drug interactions.
• Social/Habits/other: as relates to/informs the presentation and/or is relevant to that clinic
• Family history: Focus is on heritable illness amongst first degree relatives
• Physical Exam: VS and relevant findings (or their absence)
• Key labs, imaging: For a cardiology clinic patient, this would include echos, catheterizations, coronary interventions, etc.
• Summary, assessment & plan(s) by organ system and/or problems. As many systems/problems as is necessary to cover all of the active issues that are relevant to that clinic.
• Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI. He was referred by Dr. Goins, his PMD.
• The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial leads.
• Taken urgently to cath, where 95% proximal LAD lesion was stented
• EF preserved by Echo; Peak troponin 10
• In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
• Uncomplicated hospital course, sent home after 3 days.
• Since home, he states that he feels great.
• Denies chest pain, sob, doe, pnd, edema, or other symptoms.
• No symptoms of stroke or TIA.
• No history of leg or calf pain with ambulation.
• Prior to this admission, he had a history of hypertension which was treated with lisinopril
• 40 pk yr smoking history, quit during hospitalization
• No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers and was never treated with meds.
• History of depression, well treated with prozac
• Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in addition he takes Prozac for depression
• Taking all of them as directed.
• Patient lives with his wife; they have 2 grown children who are no longer at home
• Works as a computer programmer
• Smoking as above
• ETOH: 1 glass of wine w/dinner
• No drug use
• No known history of cardiovascular disease among 2 siblings or parents.
• Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
• Lungs: clear to auscultation
• CV: s1 s2 no s3 s4 murmur
• No carotid bruits
• ABD: no masses
• Ext; no edema; distal pulses 2+
• Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
• EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate LVH
• Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose 100, LDL 170, HDL 42.
• EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
• Plan: aspirin 81 indefinitely, Plavix x 1y
• Given nitroglycerine sublingual to have at home.
• Reviewed symptoms that would indicate another MI and what to do if occurred
• Plan: continue with current dosages of meds
• Chem 7 today to check k, creatinine
• Plan: Continue atorvastatin 80mg for life
• Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
• Plan: AAA screening ultrasound

Verbal Patient Presentations: A Practical Guide for Medical Students

In the hospital and clinic, medical student verbal patient presentations convey important information to the team. Time is of the essence, so concise and logical presentations of the relevant information will set students apart. The overall format for the verbal presentation is similar to the written note, but is usually more concise. Being able to select the pertinent information and present it in an efficient manner takes organization and practice, but it is a skill that can be learned. This resource is practical guide for medical student verbal patient presentations to the healthcare team along with a sample verbal patient presentation. Our institution has used this with M1 and M2 students in clinical skills, but we have also used it for verbal presentations of case patients in small-group case-based learning. This guide reflects my preferences as a family medicine physician. There are many ways to present, so students will need to be ready to adjust to the preferences of other attending physicians throughout medical school. #Communication #education #medicine #training

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Mark Almont 05-05-2021 03:44

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A guide on how to structure a case presentation

This article contains...

-History of presenting problem

-Medical and surgical history

-Drugs, including allergies to drugs

-Family history

-Social history

-Review of systems

-Findings on examination, including vital signs and observations

-Differential diagnosis/impression

-Investigations

-Management

Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history. Consultants make decisions about patient care based on information presented to them by junior members of the team, so the importance of accurately presenting your patient cannot be overemphasised.

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to …

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Home > Blog > Mental Status Exam (MSE) Cheat Sheet & Checklist

Mental Status Exam (MSE) Cheat Sheet & Checklist

Salwa Zeineddine

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As helping professionals, our primary aim is to gain a thorough understanding of those who seek our guidance.

There exist various respectful avenues for cultivating knowledge about an individual's experiences and circumstances, whether through brief check-ins or more extended discussions.

Often, a carefully organized interview allows for in-depth learning about how someone functions and behaves in their daily life.

One of the most widely used formats for evaluation in psychology, psychiatry, and related domains is the mental status examination (MSE) .

Conducting a mental status examination provides a thoughtful lens into an individual's presentation at a specific time, illuminating strengths as well as struggles.

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In this blog, we aim at Mentalyc to describe the standard components of the mental status examination process while offering suggestions for carrying it out respectfully and insightfully. Several templates, checklists and descriptors are also included to support comprehensive examinations.

Setting the Stage: What is a Mental Status Exam?

In mental health, professionals do not rely on intrusive physical examination techniques like palpation or auscultation. Instead, they focus on being expert observers, keenly noting both positive and negative findings to gain insights into an individual's cognitive, emotional, and behavioral functioning. One way to achieve that is the Mental Status Examination (MSE).

Originally developed for use in psychiatry and clinical psychology, the MSE has also found its application in other helping professions like social work and coaching. It serves as a valuable tool to document and evaluate an individual's mental state at a specific point in time.

The MSE typically involves a structured interview and systematic behavioral observations. While there may be variations in the specific forms used by different practitioners, there are core domains that should be covered in every MSE, which we aim to tackle in this blog.

MSEs are an integral part of mental health assessments and clinical contacts . They offer a holistic assessment of a patient's cognitive and behavioral functioning, based on both the clinician's observations and the client's subjective descriptions.

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Think of the MSE as a psychiatrist's version of a physical exam , but focused on mental health. It allows behavioral health professionals to create a comprehensive picture of an individual's present moment, capturing their mental state at that specific time, identifying any areas of concern, and recognizing any potential for interventions.

Key Principles in the Approach to the Mental Status Exam (MSE)

When conducting a Mental Status Examination (MSE), it is essential to adhere to certain key principles to ensure a comprehensive and accurate assessment of an individual's mental state. These principles help create a conducive environment for the patient, promote open communication, and consider various factors that may influence the assessment process. Here’s the secret recipe from Mentalyc!

Welcome and Establish Comfort:

Begin the MSE by warmly welcoming the patient and clearly stating the purpose of the meeting. Make them feel comfortable and at ease, as this can contribute to their willingness to share openly. Acknowledge any concerns or distress they may have and assure them that their privacy will be maintained throughout the assessment.

Maintain Privacy and Respect:

Privacy is crucial during the MSE. Ensure that the assessment takes place in a private and confidential setting. Encourage open conversation by actively listening and showing respect for the patient's thoughts, feelings, and experiences. Validate their concerns and distress, creating a safe space for them to express themselves.

Documentation:

When documenting the MSE, it is important to write down the patient's words exactly as they are expressed. This helps prevent misinterpretation and ensures accuracy in capturing the patient's thoughts and experiences. Pay attention to the order in which the patient expresses their words, as this can provide valuable insights into their mental state.

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Consider individual factors:.

Take into account the patient's age, culture, ethnicity, language, and level of premorbid functioning. These factors can influence the way individuals express themselves and may require additional considerations during the assessment process. For example, if the patient speaks a different language, it may be necessary to involve an interpreter to ensure fairness and accuracy in the assessment.

Consider Physical Health:

Recognize that physical health problems can impact an individual's mental state. Be mindful of any physical health conditions or medications that may influence the patient's cognitive, emotional, or behavioral functioning. Consider how these factors may contribute to their overall mental well-being.

Distinguish MSE from the MMSE:

It is important not to confuse the Mental Status Examination (MSE) with the Mini-Mental State Examination (MMSE). While the MMSE is a brief neuropsychological screening test for cognitive impairment and suspected dementia, the MSE encompasses a broader assessment of various aspects of mental functioning. However, the MMSE can be used as a more detailed cognitive assessment within the MSE.

Now, Let’s Delve into the Content of the MSE

The MSE includes ten key aspects that should be evaluated: appearance, behavior, speech, mood, affect, thoughts, perception, cognition, insight, and judgment. These domains provide a comprehensive understanding of an individual's mental state and contribute to the formulation of a working diagnosis.

I. Appearance

Observing a patient's appearance and clothing can provide initial clues about their mental state. However, it is essential to recognize that a well-groomed appearance does not always indicate good mental health. Here are some key points to consider:

Grooming: While a patient may appear well-groomed, it is important to inquire further about their personal care. Ask if they find attending to their personal hygiene difficult, if they need prompting, or if they require physical assistance. This helps uncover any potential challenges they may be facing in maintaining their personal care.

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Clothing Choice: Assess whether the patient has dressed appropriately for the season, setting, and occasion. Additionally, consider if their clothing reflects their mood. Bright, dark, or dull clothing choices may provide insights into their emotional state.

Cleanliness and Hygiene: Note whether the patient's clothes are clean and in wearable condition. This can indicate their ability to maintain basic hygiene and take care of their belongings.

Assess whether the patient has recently stopped looking after themselves or if there has been a decline in their self-care routines. This may indicate a deterioration in their mental health or the presence of other underlying issues.

Also inquire if the patient needs help or prompting with personal hygiene tasks. This can shed light on their ability to independently manage their self-care.

Posture and Gait: O bserving a patient's posture and gait can provide additional information about their mental and physical well-being. Assess whether the patient's posture is closed, slouched, or open. Closed or slouched postures may indicate a lack of confidence or emotional distress. Additionally, look for any signs of postural instability, which may suggest neurological or physical issues.

Furthermore, observe the patient's gait and note any abnormalities. Their gait may be brisk, slow, hesitant, propulsive, shuffling, ataxic, or uncoordinated. These observations can provide insights into potential motor or neurological impairments.

Additionally, be vigilant for signs of alcohol abuse and withdrawal symptoms such as tremors, tachycardia, pallor, perspiration, and neurological signs like ataxia, nystagmus, ophthalmoplegia, dysarthria, or peripheral neuropathy.

Common Descriptors: Clean, Shaven, Neat, Unshaven, Disheveled, Hair Brushed, Fashionable, Dirty, Body odor, Bizarre, Inappropriate, etc.

II. Behavior

By carefully observing a patient's non-verbal communication, clinicians can gain valuable insights into their current mental state. These observations, along with other components of the assessment, contribute to a comprehensive understanding of the patient's mental health.

Attitude: Observe the patient's attitude, which can range from cooperative to hostile, open to secretive, evasive to suspicious, apathetic to distracted, and defensive. This provides insights into their current mental state and level of engagement.

Gestures: Gestures play a crucial role in non-verbal communication. They can indicate language comprehension, sensory integration, and motor behavior. Pay attention to gestures as they can provide clues about semantic retrieval, learning, and communicative ability.

Mannerisms: Mannerisms, such as unusual repetitions, compulsions, or rituals, can be symptomatic of various psychiatric disorders. Take note of any repetitive behaviors or actions that may be indicative of an underlying condition.

Eye Contact and Body Language: Assess the patient's ability to maintain eye contact. Additionally, observe their posture, which can be open, closed, engaged, poor, or distracted. Eye contact and body language offer insights into their level of comfort, engagement, and emotional state.

Facial Expressions: Facial expressions can reveal a wide range of emotions, including happiness, anxiety, sadness, alertness, anger, distrust, suspicion, and tearfulness. Pay attention to the patient's facial expressions as they provide valuable information about their emotional state.

Psychomotor Activity: Observe the patient's level of psychomotor activity. This includes assessing for rapid talking, pacing around the room, tremors, foot tapping, psychomotor slowing (which may indicate depression), or elation. These observations can indicate underlying psychological or neurological conditions.

Disinhibited Behavior: Disinhibited behavior refers to a disregard for social conventions, affecting motor, instinctual, emotional, cognitive, and perceptual aspects. Look for signs of disinhibition or impulsivity, as they can be indicative of certain mental health conditions.

Abnormal Movements: Abnormal movements may indicate underlying organic conditions or medication-related side effects. If the patient is on antipsychotic medications, a thorough examination for extrapyramidal side effects should be conducted. These movements can include orobuccal dyskinetic movements, tics, akathisia, Parkinsonian tremor, choreiform movements, dystonia, or catatonic features.

Common Descriptors: Avoidant, Tension, Decreased activity, Limp, Agitation, Restless, TICS, Grimacing, Lip pursing, Tongue writhing, Chewing, Lip smacking, Evasive, Guarded, Passive, Sullen, Withdrawn, Demanding, Hostile, Overly friendly, Relaxed, Open, Shy, Playful, Candid, etc.

I II. Speech

Here are some key aspects to consider:

Paralinguistic Features: Pay attention to paralinguistic features such as volume, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, and latency of speech. These features provide insights into the patient's emotional state and overall communication style.

Rate and Flow: Assess the rate and flow of the patient's speech. Is it within the normal range, rapid (which may indicate mania), or slow (which may indicate depression)? Note if there is a paucity of content, characterized by a lack of meaningful information, which can be seen in depression or as a negative symptom of schizophrenia. Additionally, observe if the patient provides short monosyllabic answers to questions or exhibits pressure of speech, which is characterized by a rapid and pressured speech pattern often seen in mania.

Quantity: Evaluate the quantity of speech. Is the patient talkative, spontaneous, and expansive in their speech? Or do they exhibit paucity or poverty of speech, with limited verbal output? These observations can provide insights into the patient's thought processes and overall mental state.

Tone: Dull and monotonous speech may be indicative of depression, while normal prosody refers to the usual intonation and lilt in speech. Note if the patient's speech is loud, whispered, or tremulous, as these variations can provide additional information about their emotional state.

Fluency and Rhythm: Assess the fluency and rhythm of the patient's speech. Is their speech slurred, clear, hesitant, or articulate? Note if there are any signs of aphasia, which is a language disorder that affects the ability to articulate and comprehend speech.

Route: Pay attention to the route of the patient's speech. Circumstantial speech, characterized by excessive and unnecessary detail, may indicate obsessive traits or anxiety. Tangential speech, on the other hand, involves veering off-topic and may be seen in individuals experiencing mania.

Other Common Descriptors: Dysarthric, Slurred, Monotone, Soft, Loud, etc.

Observe and describe the patient's pervasive emotional state. Is their mood elated, dysthymic (chronically low mood), euthymic (within the normal range), apathetic, blunted (reduced emotional expression), or irritable? Note any signs of depression.

Mood Changes: Assess if the patient's mood changes throughout the meeting or evaluation. Do they experience fluctuations in their emotional state? Note any triggers or patterns that may contribute to these mood changes.

Encourage the patient to describe how they have been feeling recently. Ask open-ended questions to allow them to express their emotions in their own words. Note their exact words and verbatim to accurately capture their subjective experience.

Ask the patient if they have been feeling irritable, angry, depressed, discouraged, or unmotivated recently. Encourage them to elaborate on these emotions and their intensity. This helps to gain a deeper understanding of their emotional state and any associated distress.

Other Common Descriptors: Depressed, Irritable, Sad, Angry, Fantastic, etc.

Affect refers to a patient's moment-to-moment expression of emotions, which can be observed through their posture, movements, body language, facial expressions, and tone of voice. It is important to note that in this section, no questions are asked, and the assessment is purely observational.

Here are some descriptors to consider when assessing a patient's affect:

Intensity: Evaluate the intensity of the patient's affect. Is it within the normal range, blunted (reduced emotional expression), or flat (absence of emotional expression)? This observation provides insights into the patient's emotional responsiveness.

Quality: Assess the quality of the patient's affect. Does their affect appear sad, agitated, hostile, or any other specific emotional quality?

Fluctuation: Observe if the patient's affect is labile, meaning it easily fluctuates or changes in response to stimuli. Labile affect may indicate emotional instability or difficulty regulating emotions.

Range: Evaluate the range of the patient's affect. Is it restricted, meaning limited in the variety and intensity of emotions expressed? Or is it expansive, with a wide range of emotions displayed? A normal range of affect indicates a healthy emotional expression.

Congruence: Determine if the patient's affect is congruent or incongruent with their verbal content or the situation at hand. Congruent affect means that the patient's emotional expression aligns with their words and the context. Incongruent affect refers to a mismatch between the patient's emotional expression and their verbal or situational cues.

VI. Thoughts

Content of Thought: Ask the patient what has been on their mind recently. Inquire if they have any worries or concerns.

Explore if they have ever felt that life isn't worth living.

Ask if things seem unreal or distorted to them.

Assess if they have any thoughts that they can't get out of their head. Assess for suicidal and homicidal ideation, conducting a thorough risk assessment.

Observe for the presence of delusions, which are false beliefs that are firmly sustained despite evidence to the contrary.

Look for ideas of reference and delusions of reference, where the patient believes that events, objects, or other people have a particular and unusual significance.

Stream of Thought: Observe the quantity and speed of the patient's thoughts. Are their thoughts blocked or pressured? Do they experience poverty of thought? Note if the patient's thoughts are logical and linked together, or if they are tangential, replying to questions in an oblique or irrelevant way. Look for signs of thought possession, such as thought insertion, thought withdrawal, or thought broadcasting.

Form of Thought: Note if their thoughts are organized and linked together, or if they exhibit word salad, where speech or thinking is incomprehensible due to a lack of logical or meaningful connection.

Look for signs of derailment, where their ideas slip off one track onto another unrelated or obliquely related track.

Pay attention to clang associations, where the sound of a word, rather than its meaning, guides subsequent associations.

Observe if the patient's speech is pressured, increased in amount, accelerated, and difficult to interrupt.

Note if there is a reduction in the quantity of thought, known as poverty of thought.

Look for signs of blocking, which is a sudden interruption of thought or speech.

Observe if the patient refuses to speak, known as mutism.

Note if the patient engages in echolalia, which is the meaningless repetition of the examiner's words.

Pay attention to the use of neologisms, which are new words formed by the patient to express their ideas.

Common Descriptors: Blocking, Tangential, Word salad, Impoverished, Incoherent, Circumstantial, Loose, Rapid, Distractible, Perseverative, Flight of ideas, etc.

VII. Perception

Perception is the process by which we become aware of the stimuli presented to our body through the sensory organs. It involves the interpretation and processing of sensory information to make sense of the world around us. However, in certain cases, perception can be altered, leading to the presence of hallucinations and illusions.

Hallucinations can be defined as perceptions that occur in the absence of any external stimulus. They are sensory experiences that are not based on real sensory input. Hallucinations can affect any of the senses, including sight, hearing, taste, smell, and touch. Common types of hallucinations include seeing things that are not there (visual hallucinations), hearing voices (auditory hallucinations), or feeling sensations that are not present (tactile hallucinations). Hallucinations can be a symptom of various medical and psychiatric conditions, such as schizophrenia, substance abuse, or certain neurological disorders.

Illusions, on the other hand, are misinterpretations of real sensory stimuli. They occur when the brain incorrectly perceives or interprets sensory information. Illusions can occur in any of the senses and can be influenced by various factors, such as lighting conditions, cognitive biases, or prior experiences. For example, an optical illusion may cause us to perceive an image differently than it actually is, or a misinterpretation of a sound may lead to a false perception of its source.

When assessing a patient's perception, it is crucial to inquire about the presence of hallucinations and illusions. Questions to consider may include:

Have you experienced any sensory perceptions that others around you do not seem to perceive?

Do you ever see, hear, smell, taste, or feel things that are not actually present? Have you noticed any misinterpretations of sensory stimuli, where you perceive something differently than it actually is?

Common Descriptors: Tactile hallucinations, Derealization, Auditory hallucinations, Olfactory hallucinations, Depersonalization, Visual hallucinations, Illusions, etc.

VIII. Cognition

The cognition section focuses on assessing various aspects of cognitive functioning, including orientation, attention, memory, alertness, and visuospatial functioning. It provides valuable insights into the patient's awareness of self, environment, higher cortical functioning, frontal functioning, and language abilities.

Orientation refers to the patient's awareness of time, place, and person. It assesses their ability to accurately answer questions such as the current time, date of birth, age, and their current location. Questions like "What is the date today?" or "Can you tell me where we are right now?" help evaluate the patient's orientation to time and place.

Awareness of the current setting is another important aspect of cognition. It involves assessing the patient's understanding of the situation they are in. Questions like "What is your full name?" or "How would you describe the situation we're in?" can help determine if the patient has a clear awareness of their current setting.

The section may also include the administration of a mini-mental status examination (MMSE). The MMSE is a brief screening tool used to assess cognitive impairment. It evaluates various cognitive domains, including orientation, registration (immediate memory), attention and calculation, recall (short-term memory), etc.

IX. Insight and Judgment

To gain insight into the patient's understanding of their mental health problem, it is essential to gather information directly from their perspective. This can be achieved through open and empathetic communication, allowing the patient to express their thoughts, feelings, and beliefs about their mental health condition.

Insight and judgment are closely related, as insight refers to the patient's awareness and understanding of their mental health condition, while judgment pertains to their ability to make sound decisions and solve problems effectively. Both aspects provide valuable information for treatment planning and intervention strategies.

Common Descriptors: Good, Fair, Poor, etc.

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Whenever you find yourself in need of assistance, rest assured that we are here to lend a helping hand. Our team is dedicated to providing the support you require for all your checklists and form needs.

Our doors are always open, welcoming you with open arms. Whether you reach out to us through a message or a call, we are just a moment away!

References:

• Kaplan and Saddock’s Synopsis of Psychiatry 10th Ed. Chapt. 7 – Clinical Examination of the Psychiatric Patient

All examples of mental health documentation are fictional and for informational purposes only.

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How to Skillfully Present Patients in Medical School

Get 100+ free tips i wish i got on my first day of med school.

Disclosure: This post may contain affiliate links which means I may get a commission if you make a purchase through my link at no additional cost to you. Thank you for your support!

How do you present patients in medical school? Presenting in front of attendings often makes medical students tense up. It’s very uncomfortable to attempt to sound competent, concise, and thoughtful to a likely evaluator.

But what if I told you that the whole process could be stress-free and easy?

In this post, I’ll break down, step-by-step, exactly how to present patients in medical school to your attendings/residents. This will include the dos and the do not’s of presenting!

If you prefer a video format, check out the following video and more on my YouTube channel!

Tell a Story When Presenting Your Patient:

This is how I learned to present, and I believe it’s the best way to present patients.

Tell a story.

You know how easily we mentally check out during a boring lecture. They often just read off their slides. It becomes a bullet point presentation – just fact after fact.

Medical students are often the boring lecturer when they present. We become so worried about telling all the facts. But we suck at tying it all together.

Think about it; we don’t talk about patient experiences with our peers the way we present. We’re much more casual and hit the high points, Now no I’m not arguing that you should be too casual but learn how to tell a story without hitting unnecessary info.

I’ll break down exactly how I tell my patient’s medical story. Just remember that you want to be interesting and concise.

What Would I Want To Hear?

Imagine yourself as the attending. What would you want to hear?

You certainly wouldn’t want to hear your medical students telling you about lung sounds in a patient with a broken finger.

Ask yourself if a piece of info is important for your patient. You get better over time on identifying what’s important. I discuss some things you should always mention later in the post.

Write Out Your Presentation in Bullet Format

Too often I see my peers reading their typed notes word for word. They rarely look up and don’t even pretend like they’re not just regurgitating their progress note.

I get that it’s hard to memorize a presentation. It’s as scary as actually having to do one.

So use a bullet point outline.

Here’s what I do.

On the first bullet, I’ll often write a shrunk version of my one-liner. I’ll talk about mastering this later in the post.

The next few bullets I’ll break down symptoms, timeline, important features, etc. that I want to discuss when I’m telling my patient’s story.

In the next bullet points, I’ll write the vital ranges and underline anything I want to mention. I’ll also include physical exam findings and labs which are pertinent.

Finally, I’ll include a list of problems with Ddx and suggestions for the plan.

Here’s an example of what this would look like.

Honestly, this is probably more than I’d write down. I have created my abbreviations which tends to cut my bullet point to half what’s shown above.

Unless I’m lost,I don’t have to look down. Thus I’m always making eye contact with my attending – demanding attention.. This makes the presentation seem much more natural. You’re having a discussion with your attending.

Don’t read your note that they can read on their own.

S tep-By-Step Approach To Presenting Patients in Medical School  Master the One-Liner.

Your one-liner will tell the resident if they should take your presentation seriously or not. The same way a great singer grabs your attention with their first note, you have to impress with a solid one-liner.

Here’s how to do it.

Table Of Contents

Who are they?

Include their name, age, and demographics.

Why predisposes them to these symptoms/disease?

What comorbidities do they have? Which are important for their current chief complaint?

Provide some insight into severity here. Do they have HF? If so what’s their ejection fraction?

Do they have diabetes? What’s their A1C?

I discuss other examples later in the post.

Why are they here?

Their chief complaint is the most important part of your one-liner. Here are things you must include.

What caused them to come into the hospital/clinic?

Patients usually come in with symptoms, not diagnoses . So your patient comes in with a chief complaint of chest pain, not a heart attack.

Sometimes a patient may come in for one thing but are getting worked up for a different symptom altogether. You can state, “patient is being evaluated for (insert symptom) that was identified in the emergency room/clinic”. You can include in your HPI what the patient originally came in for to paint the full picture.

Master Your PHI (Present History of Illness)

I remember presenting once in the pediatric emergency room to an attending. My patient was a 6-year old girl with a cat scratch to her eye. It was my first rotation, and I had no idea what I was doing (Maybe I should have looked for such a post back then).

I began with a killer one-liner. But then, instead of talking about her eye, I began to talk about her flu-like symptoms. The attending immediately stopped me and said, “I don’t care! Tell me about her eye!”.

So learn from my mistake. Don’t talk about the flu on a patient with a scratched eye.

Keep your story to the point.

After you understand this important lesson, the next step is to begin to form the order of your story. Often this begins with how the long the symptoms are going and how they first presented. Then provide a chronological order of how the symptoms worsened/improved over time.

Make sure to include why the patient finally came to see a doctor. Why now instead of two days ago when the symptoms first started?

This is also where you include the rest of your PHI. There are several acronyms people use that I haven’t cared to remember. But here are the important details to discuss (if applicable).

How long have the symptoms lasted? How does the patient describe their symptoms/pain? (sharp, dull, throbbing, etc.) Where is it? Does it radiate? How severe on a scale of 1-10 is it? Has this number gotten worse or better over time? What makes it better and what makes it worse? Do they have any other associated symptoms? (Fevers, weakness, headaches, chest pain, etc.)

Remember not everything is important:

Let’s go back to our bullet point outline of our presentation. When you practice it in your head, ask if that fact you plan on saying is important to the person’s story.

Ever watch a movie and wonder why a scene was even needed? Don’t include extra scenes.

The attending should understand who the patient is, why they’re here, and the important events that led them to this point.

What is considered abnormal?

If something is abnormal to a patient, explain how it differs from normal for them. If a patient can’t walk without being SOB, you must explain how far could they walk before.

If they have a headache but also have a history of migraines, then you must include how this headache is different or similar to their condition.

Indicate Pertinent Positive and Negatives on

If a patient comes in with concerns of a heart attack, including the symptoms that they have which make you worried.

It’s equally as important to include symptoms of an MI that they don’t have.

But don’t go through the whole list and indicate random symptoms that don’t matter.

Become Efficient in Telling The Past Medical

Students love to list everything the patient has. But let’s be real, I don’t care if a patient has GERD and they’re coming in for osteomyelitis.

In your PMH include big comorbidities such as diabetes, asthma/COPD, heart failure, liver disease, and kidney issues.

If they do have the above comorbidities here are some things you should include.

For diabetes always include their most recent A1C. State when this was done. Also include what form of treatment they’re on (insulin, metformin, etc.), their dose, and their compliance with their medications. Also ask about their typical blood sugars, how often the measure them, and what time of the day these readings are taken.

For heart failure include their last ejection fraction and date. Indicate what medications they’re currently taking and how compliant they are. Ask the patient how many pillows they sleep with under their head as paroxysmal nocturnal dyspnea is a common symptom. Also, ask about their baseline weight (will go up in a heart failure exacerbation) and what their diet/fluid intake is like.

For asthma , you want to identify what severity they have. Are they severe persistent, moderate intermittent, or something else? How often do they use their rescue inhaler? How many times a week do they wake up at night. Also, ask if they’ve ever had to be intubated before.

Similar to asthma, for your COPD patient also include what GOLD stage they are. You’ll learn about this on your internal medicine rotation if you haven’t already.

These are some classic examples you want to hit every time.

Physical Exam

Start with their vitals.

Do you need to say everything? No.

Some attendings will want ranges for the heart rate and blood pressures. Others are fine if you say, “patient is afebrile, normotensive, and has a regular heart rate” or “vital signs are within normal limits”.

Regarding your physical – only say what you did. Again does everything matter? Nope.

Get away from sounding robotic. “Lungs clear to auscultation bilaterally” can just be “lungs clear bilaterally”.

If you don’t read your notes, you’ll seem more natural when presenting the physical.

What about labs?  Don’t present all labs obviously. No one cares about the WBC for a patient with a broken arm.

State labs of importance such as “lytes were stable; hemoglobin was decreased to (insert value) from (insert value) yesterday. Remaining labs of patients were within normal limits”.

If, however, you did a specific lab/test to confirm/rule out a disease then make sure you state the results. A common example is a urinalysis. If a patient has suspected UTI, make sure you state their UA came back without indications for an infection.

Certains labs are important to trend. This includes Creatinine, BNP, hemoglobin/hematocrit, WBC, Platelets, Lactate, and important electrolytes.

Assessment and

So you finished with the easy part. You knew the story and told it. Now you get to show you know how to doctor and not just interview.

Here’s my format to present my assessment and plan.

“This is Ms. who has (insert pertinent conditions and PMH) who came in for (symptoms). Given her symptoms and (physical exam/lab evidence A, B, C) I think she could have (differential A) given that she has (x,y, and z), she could also have (differential B) because of (x,y,z) and differential C (x,y,z).

To work her up I would do test/treatment (a,b,c) and reevaluate her (insert time frame).

I expect discharge for her pending treatment/workup and hopeful discharge (give a guess if possible).”

Boom! You just rocked that patient presentation!

If your patient has multiple problems, you can break your A/P by problem. For example, you can state, “For her back pain I think she could have (X,Y, or Z). I think we should give her treatment (A or B).” Keep going down her problem list. Some attendings like a system based but the method is the same.

Whenever you’re ready, there are 4 ways I can help you:

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So there you have it. Now you can present patients in medical school like a pro!

Here are other posts you may enjoy as well.

How to Build Strong Relationships with Your Patients Dealing With Death in Medical School Regaining Motivation in Medical School Top Resources to Honor Your Pediatrics Rotation

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08 29 5 elements header

Download the Slides

Introduce your team to the Five Elements: download the ambulatory and/or inpatient slides below.

• Ambulatory PX5 Slides:  PPT
• Inpatient PX5 Slides:   PPT

What is patient experience?

very week, our organization receives an average of 8,000 patient comments. Most of them describe a range of experiences and journeys: anxiety, pain, and worry, but also respect, comfort, and often—hope.  

A patient’s experience begins the moment they choose or are referred to our system. Their experience describes their entire care journey—from scheduling an appointment, seeing a specialist, an inpatient stay, filling their prescriptions, follow-up appointments—to whatever the outcome may be.  

Whether building health, a simple cold or a chronic condition, each step in the patients’ entire care experience matters.

What makes an experience exceptional?

In 2008 , patient experience at U of U Health wasn’t so great. The system faced frequent patient complaints, including poor communication, long waits to schedule appointments, lack of care coordination, and unprofessionalism. This prompted then-Senior Vice President Dr. A. Lorris Betz to challenge every leader in the system to improve with the statement, “Medical care can only be great if the patient thinks it is.”

“Medical care can only be great if the patient thinks it is.”

Finding the five elements

To improve, we started listening to the voice of our patients— every single one.  

In 2010, University of Utah took the lead as the first health system in the country to move from a paper survey to using an electronic survey of patients’ care experiences. Very quickly, we were inundated with incredibly descriptive feedback . Patients began sharing their stories—worries, joys, what happens when we (the health care system) mess up, what’s hard about a particular diagnosis, and what’s amazing about their particular care team, from support staff to physician. 

In 2023, we expanded our method of collecting feedback to be more timely and inclusive. Using short, flexible question sets with an aim to reduce burden on the patient and leverage smart triggers from our electronic medical record, we doubled the amount of feedback coming in.

Needles in a haystack

Now, every year we receive approximately 220,000 surveys that generate over 220,000 patient comments. It was (and is) a firehose of information to digest.  

To make sense of this massive amount of information, we began engaging partners in artificial intelligence in 2013. We partnered with a natural language processing firm to attempt to break down the complexity into a few, actionable insights. But after a year of analysis, the company could only tell us things we already knew—the proportion of positive or negative comments or the most frequently mentioned topic: wait time. That wasn’t good enough for U of U Health’s physicians, leaders, and staff who had already moved past simply classifying comments. What they wanted was insight—what, specifically, builds trust and loyalty with patients? How do we improve our patients relationship with our providers, teams and system? In other words, what makes a patient experience exceptional?

Five consistent themes

Where we started: The system’s department of patient experience, a team of five individuals, undertook the challenge of answering this question using qualitative analysis. In 2014, the team pulled a sample of 10,000 comments from various care settings—inpatient, outpatient services, primary care, specialty care, emergency care—and analyzed them by service line. Each comment was read, categorized, sent back to service line leadership as feedback, and then brought back to the group for discussion.  

Over time, five consistent themes emerged:

The Five Elements of Patient Experience

An exceptional patient experience reflects all five elements.  

Patients want to be known, heard, and provided a plan that reflects and includes their values, including sensitivity to their individual background. Patients want the team to coordinate for them and be on the same page with each other. Patients want the team to be organized to meet their specific needs. When all five elements are present, patients describe their confidence and trust in the care team. Patients even describe their loyalty to the health care system.  

Here is how the five elements sounds when the patient has confidence in the physician and the team is organized to meet their needs:  

Example of a five element comment:

What we learned by using the five elements with teams: Unstructured narrative feedback can be challenging for learning—survey responses tell you what occurred, but they don't tell you why something happened or details on how to improve. We learned that providing a framework to understand feedback and group it into relevant themes was helpful for frontline teams to understand what behaviors to stop/start/continue. It equipped frontline leaders and teams with clear, accessible language to translate patient feedback into domains for improvement and recognition. 

How we use the five elements

To understand patient feedback. Answers to questions on patient surveys, or the quantitative data, doesn’t provide much context. It’s the stories that shed light on why a patient needed more explanation or how asking about a patient’s family makes them feel like a person, not a diagnosis.

Identify specific behaviors to care teams to start, stop, and continue. Delivering an exceptional experience often means becoming more consistent with specific behaviors. We use the five elements to help teams understand the high-impact behaviors that create a more meaningful connection with patients.

Widen the perspective from one method of improvement. Typically, teams have focused on one area of improvement, such as efficiencies around wait time. Managing wait time is important, but its equally important to demonstrate consistent behaviors in the other four areas. The five elements helps broaden improvement opportunities beyond one path of improvement.

To onboard new team members. There are many abbreviations and mnemonics in health care designed to provide short cuts to best practice guidelines. But sometimes those guides can turn into scripting that doesn’t feel authentic. The five elements provides a platform to personalize key behaviors that matter across care environments without an overreliance on scripting. Leaders use the five elements to engage teams, especially new members, to build consistent practice.

Respond during the Covid pandemic. We applied the five elements model to understand feedback during the pandemic and surface high-impact behaviors for care teams across the health care system.

Its been 10 years since we developed this framework and much has changed in health care - an international pandemic, growing importance of digital tools, and an imperative to improve health equity. The 5 element framework continues to help us respond by centering the voices of our patients and our communities. We now leverage real-time feedback and machine learning to support reading  every single comment that patients share with us. We listen for the five elements and share the patient voice directly with our care teams. We recognize individuals and teams by highlighting patient experiences demonstrating the five elements.   

And as a result, University of Utah Health has become a national leader in delivering compassionate, coordinated, and expert care. Over the past 15 years, patient experience has become the cornerstone for initiatives focused on quality and safety, patient-reported outcomes, and cost reduction.

Acknowledgement

Thank you to the contributions of past and present Patient Experience team members: Chrissy Daniels, Corrie Harris, Marcie Hopkins, Kristen Mauck, Brittany Patterson, and Brandon Swensen.

Ember Hunsaker

Mari ransco, kathryn young.

Our words can build, or erode, trust with others. Manager of Patient Experience Operations Ember Hunsaker offers insight into how our words may be helping, or harming, those around us and how to balance the scales.

University of Utah Health’s director of patient experience Mari Ransco examines the pandemic patient experience through the lens of the 5 Elements: U of U Health’s qualitative model for delivering an exceptional patient experience.

The patient experience team shares resources to build coordination and teamwork centered on the needs of patients, caregivers, and families.

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Contact the Accelerate Team

50 North Medical Drive   |   Salt Lake City, Utah 84132   |   801-587-2157

Patient Presentations Infographic Full Text

New section.

About This Graphic

This infographic shows seven tips for effective patient presentations and is part of the Posters and Abstracts section of the Presentation Skills Toolkit for Medical Students. Each of the seven tips includes a heading for the tip followed by a brief description and an illustration.

Quick Tips for Effective Patient Presentations:

Know expectations..

There is an illustration of binoculars. The text reads, "Preferences for presentations can vary between specialties and attendings in terms of length and style."

Be concise.

An illustration shows three sheets of paper entering a box with arrows pointing down. Below that a single piece of paper enters a funnel. The text reads, "Succinctly convey the most essential patient information in a logical way to tell the patient's story."

Synthesize information.

An illustration shows an eight-pointed star with a circle at each point. There is an outline of a person in four of the circles. The text reads, "Present organized, accurate information that highlights the points you think are most relevant."

Engage your listeners.

An illustration shows two overlapping rectangles with lines leading to three circles, each of which contains the outline of a person. The text reads, "Deliver your presentation in an organized, clear, and professional manner with good eye contact."

Be mindful of your audience.

An illustration shows the outline of a person with waves next to their ears, suggesting sound. There are eight smaller outlines of person surrounding the person. The text reads, "Adjust accordingly for different settings, including bedside presentations."

Keep it patient-centered.

An illustration shows two open hands reaching upward holding a human brain. The text reads, "Advocate for your patient using language that is kind, empathetic, and non-judgmental. Know your biases and work to counteract them."

An illustration shows five medical professionals standing in a row. Four of them wear lab coats, and one wears scrubs. The text reads, "Take every opportunity to present patients and practice before you present to your team."

Clinical Words to Use in Progress Notes

By Gale Alagos on Aug 13, 2024.

Fact Checked by Nate Lacson.

What are progress notes?

Have you ever wondered how practitioners in different fields keep track of a patient's journey toward recovery or how nurses communicate a patient's response to treatment? The answer lies in progress notes .

Progress notes are an essential part of medical documentation, providing a comprehensive record of a patient's condition, treatment, and progress over time. These notes serve as a crucial communication tool among healthcare providers, ensuring continuity of care and enabling informed decision-making.

These can be considered as clinical process notes which typically include a detailed account of a patient's current status, including their chief complaint, subjective symptoms, objective findings from physical examinations or diagnostic tests, assessments, and the treatment plan. They also document any changes in the patient's condition, responses to interventions, and any additional information relevant to their care.

Clinical Words to include in your treatment plan

When documenting the treatment plan, appropriate clinical terminology can help convey important details accurately and efficiently. Here, we'll explore specific terms to describe a patient's condition, their response to treatment, and any interventions implemented.  Incorporating this vocabulary can help healthcare professionals craft notes that are not only accurate but also foster better communication and collaboration among healthcare providers.

1. Clinical Words to describe cognition (thought process)

Moving beyond physical health, progress notes also play a vital role in documenting a patient's mental state, particularly their cognition (thinking process). Choosing the right words here paints a clear picture for fellow healthcare providers and contributes to a more holistic understanding of the patient's well-being.

Let's delve into some key terms to describe a patient's cognition:

• Alertness and orientation: This refers to a patient's awareness of their surroundings and ability to answer basic questions about themselves (name), location (hospital, room), time (day, date), and situation (reason for hospitalization).
• Attention and concentration: These terms describe a patient's ability to focus, sustain their attention on a task, and filter out distractions.
• Thought process: This refers to the organization, flow, and clarity of a patient's thinking. Is it linear and logical, or are there signs of circumstantiality (wandering details) or tangentiality (jumping from topic to topic)?
• Mood and affect: These terms differentiate between a patient's emotional state (sadness, anxiety) and their outward expression of emotions (crying, restlessness).
• Insight and judgment: These terms assess a patient's understanding of their condition and ability to make sound decisions regarding their care.

2. Descriptive intervention words for progress notes

Progress notes aren't just about documenting a patient's condition – they also detail the interventions implemented to promote healing.  Here, using precise and descriptive action verbs becomes crucial.  These verbs not only clarify the type of intervention used but also paint a clearer picture of the therapeutic approach.

Instead of simply stating "therapy provided," consider these options:

• Psychoeducation: This term describes educating a patient about their condition, treatment options, and coping mechanisms.
• Motivational interviewing: This intervention focuses on a patient's own desires and goals to build motivation for change.
• Cognitive behavioral therapy (CBT) : This widely used therapy helps patients identify negative thought patterns and develop healthier coping skills.
• Interpersonal therapy (IPT) : This therapy focuses on improving a patient's interpersonal relationships and communication skills.
• Medication management: This describes monitoring and adjusting a patient's medications to optimize treatment effectiveness.
• Patient education: This describes providing patients with information about their condition, treatment options, and self-care strategies.

3. Documenting symptom severity and changes

Progress notes are a vital tool for tracking a patient's symptoms and their response to treatment.  Choosing the right words here allows you to not only document the presence of symptoms but also capture their severity and any changes observed over time.

Moving beyond simply stating "depressed" or "anxious," progress notes can utilize terms that paint a more nuanced picture of symptom severity:

• Mild: Symptoms are minimal and cause little to no interference with daily life.
• Moderate: Symptoms are noticeable and may cause some difficulty with daily activities.
• Severe: Symptoms are significant and cause substantial impairment in daily life.

Additionally, consider incorporating specific terms that describe the characteristics of the symptoms:

• Frequency: How often does the symptom occur (daily, weekly)?
• Duration: How long does the symptom last (minutes, hours)?
• Intensity: How severe is the symptom (mild discomfort, debilitating pain)?

Progress notes are also not merely static documents – they capture the patient's journey over time. Here's how to document changes in symptoms:

• Improved: Symptoms have lessened in severity or frequency.
• Stable: Symptoms remain unchanged.
• Worsened: Symptoms have increased in severity or frequency.
• Remission: Symptoms have completely disappeared.

4. Capturing the client's emotional and behavioral response

Moving beyond simply stating "happy" or "sad," progress notes can utilize terms that describe the quality, intensity, and duration of a patient's emotions:

• Affect: This refers to a person's outward expression of emotion, including facial expressions, body language, and tone of voice.
• Mood: This describes a person's overall emotional state, such as depression, anxiety, or euphoria.
• Affective instability: This term describes rapid shifts in mood, with emotions changing frequently and unpredictably.

Progress notes become even more powerful when they link a patient's emotional state and behavior to specific situations or interventions. Specific examples of these include:

• Expressed tearfulness and feelings of hopelessness following a discussion of a recent loss.
• Demonstrated improved focus and concentration after initiating medication adjustments.

5. Detailing the effectiveness of coping mechanisms

Progress notes can track a patient's journey with coping mechanisms using specific terms:

• Skill acquisition: This term highlights a patient's learning of specific coping mechanisms, like relaxation techniques or cognitive reframing.
• Utilization of coping skills: This describes a patient actively applying the coping skills they've learned in real-world situations.
• Improved stress management: This describes a patient's ability to manage stress levels more effectively using coping skills.

Now, the road to mastering coping mechanisms isn't always smooth. Progress notes can capture these hurdles and adjustments:

• Difficulty implementing skills: This describes a patient struggling to apply coping skills in specific situations.
• Identification of triggers: This term highlights a patient recognizing situations that provoke negative emotions.
• Adjustment of techniques: This describes tailoring coping mechanisms to suit a patient's needs better.

6. Progress in interpersonal skills and relationships

These notes can also document a patient's journey toward improved interpersonal effectiveness using specific terms:

• Increased assertiveness: This describes a patient's ability to express their needs and desires confidently and respectfully.
• Improved communication skills: This term highlights a patient's development of clear and effective communication, both verbal and nonverbal.
• Reduced conflict: This term describes a patient experiencing fewer arguments or disagreements in their relationships.
• Strengthened social support system: This describes a patient developing and maintaining healthy, supportive relationships.

7. Observations on self-perception and self-compassion practices

Progress notes serve not only to document a patient's condition but also to capture their evolving self-perception and their efforts toward self-compassion. This is particularly significant for patients struggling with self-esteem and self-image issues.

• Increased self-awareness: This describes a patient's growing understanding of their thoughts, emotions, and behaviors.
• Reduced negative self-talk: This term highlights a decrease in self-critical thoughts and internal negativity.
• Implementation of self-compassion practices: This describes a patient actively engaging in exercises or techniques to cultivate self-compassion, such as mindfulness meditation or gratitude journaling.
• Increased self-acceptance: This term highlights a patient's growing ability to accept their flaws and imperfections without harsh judgment.

8. Objective measurements of therapy success

While documenting symptoms and interventions is crucial, incorporating objective data and clinical impressions paints an even richer picture. This allows healthcare providers to track a patient's progress not just through self-reported experiences but also through quantifiable measures and insightful observations.

• Standardized assessments: These are questionnaires or tests designed to measure specific symptoms or functioning, such as depression scales or anxiety inventories.
• Physiological measures: In some cases, physiological data like heart rate or blood pressure can be monitored to track the impact of therapy on stress or anxiety levels.
• Behavioral observations: Documenting observable changes in behavior, such as increased social interaction or improved sleep patterns, provides valuable objective data.
• Mental status examination: This standardized evaluation assesses a patient's appearance, mood, thought processes, and overall mental state.

Progress notes can highlight how these elements work together to demonstrate a patient's progress. For example:

• Standardized depression scale scores have shown a consistent decrease over the past month, aligning with the patient's reported improvement in mood and energy levels.
• Following implementing behavioral therapy techniques, the patient demonstrates a significant reduction in disruptive classroom behaviors observed by teachers.

9. Therapeutic intervention outcomes

Progress notes can also detail the interventions used, ensuring clear communication and collaboration:

• Mindfulness practices: This describes incorporating exercises like meditation or breathwork to cultivate present-moment awareness and emotional regulation.
• Cognitive restructuring: This intervention helps patients identify and challenge negative thought patterns, replacing them with more realistic and adaptive ones.
• Problem-solving skills training: This equips patients with strategies for breaking down complex problems, identifying solutions, and making effective decisions.

10. Planning for future sessions

This final section explores clinical terms to effectively document future directions , ensuring continuity of care and clear goals for upcoming sessions.

• Skills training: This describes identifying specific skills a patient needs to develop, such as communication training or relaxation techniques.
• Continued therapy: This term highlights the need for ongoing therapy sessions to solidify progress and address any emerging challenges.
• Adjusting medication regimens: Document any planned changes to a patient's medication dosage or type, ensuring clear communication with all healthcare providers involved.

Effective treatment plans require clear goals. Progress notes can utilize the SMART framework to establish measurable and achievable objectives:

• Specific: Goals should be clear and well-defined, targeting specific behaviors or symptoms.
• Measurable: Goals should be quantifiable to track progress using standardized assessments or self-reported improvements.
• Attainable: Goals should be realistic and achievable within a specific timeframe.
• Relevant: Goals should be directly linked to a patient's overall treatment plan and address their presenting concerns.
• Time-bound: Goals should have a specific timeframe for achievement, promoting accountability and progress tracking.

How to write therapy progress notes

Documenting a client's journey in therapy is essential for effective treatment and communication. While progress notes might seem formal, incorporating the right clinical words can elevate them into powerful tools for tracking client's progress and informing future interventions. These can also serve as legal documentation and a requirement by an insurance company.

Here, we touch on key aspects of writing mental health progress notes, equipping you with the vocabulary and structure to create clear, informative, and insightful documents.

When creating client notes, it's crucial to use precise clinical language that accurately conveys their presentation, symptoms, and responses to treatment. Some clinical words and phrases to consider include:

• Mental health problems/disorders (e.g., anxiety disorders, depression)
• Cognitive functioning (e.g., cognitive restructuring, problem-solving skills training)
• Subjective and objective data (e.g., client's self-report, therapist's observations)
• Coping skills (e.g., self-compassion practices, mindfulness exercises)
• Symptom description (e.g., suicidal ideation, identifying triggers)

Progress notes vs. therapy notes

While both therapy notes and progress notes document aspects of a therapy session, they serve distinct purposes.

Progress notes, on the other hand, focus on the bigger picture. They are typically more concise and shared with a broader healthcare team, providing a comprehensive understanding of the client's condition, treatment plan, and progress over time. A therapy note, unlike progress notes, is often private and captures the details of the session itself, including the client's presentation, in-session interventions, and the client's response.

When writing clinical notes, it can be helpful to have an ultimate guide for you to write more effective progress notes.

5 helpful templates and formats for mental health progress notes

Effective progress notes are the backbone of successful therapy. They document a client's journey, inform treatment decisions, foster communication with healthcare teams, and ultimately support a client's healing process. However, crafting clear and informative notes can feel overwhelming. This guide explores 5 helpful templates and formats to equip you with the structure and clinical words needed to write impactful mental health progress notes .

1. SOAP notes

The Subjective, Objective, Assessment, Plan (SOAP) note format is widely used in various healthcare settings, including mental health. This format provides a structured approach to documenting a therapy session:

• Subjective: This section captures the client's perspective on their mental health condition, including their reported symptoms, concerns, and emotional state.
• Objective: This section documents objective data, like vital signs, standardized test scores, or observations of behavior.
• Assessment: This section integrates subjective and objective information to reach a clinical impression of the client's condition and progress.
• Plan: This section outlines the patient's treatment plan, including specific therapeutic techniques such as cognitive behavior intervention or mindfulness practices, medication regimens (if applicable), and future sessions needed to achieve treatment goals.

The SOAP note format provides a clear structure for organizing information, making it a great choice for beginners or when dealing with complex cases.

2. BIRP notes

The Behavior, Intervention, Response, Plan (BIRP) format is commonly used in behavioral health settings. It focuses on documenting specific behaviors, interventions used, the client's response, and future plans:

• Background: A brief overview of the client's condition and treatment history.
• Interventions: A summary of the therapeutic interventions used in the session.
• Response: A description of the client's client's progress and response to the interventions.
• Plan: A concise outline of the next steps, including any adjustments to the treatment plan.

The BIRP format is particularly helpful for group therapy sessions or progress updates for insurance companies.

3. DAP notes

The Data, Assessment, Plan (DAP) format is a concise approach to progress note documentation. This format prioritizes key information while maintaining clarity.

• Data: Relevant information about the client's current status, including subjective reports and objective observations
• Assessment: Analysis of the client's progress, challenges, and clinical impressions
• Plan: Treatment interventions, goals, and plans for the next session or follow-up

4. GIRP notes

The Greeting, Intervention, Response, Plan (GIRP) format is particularly useful for documenting group therapy sessions. This format ensures clear communication and tracks progress within the group setting:

• Greeting : Brief introduction and check-in with group members
• Intervention: Description of the therapeutic interventions or activities conducted during the group session
• Response: Group members' responses, reactions, and progress during the session
• Plan: Plans for future group sessions or individual follow-ups

5. Narrative notes

While structured formats can be helpful, some mental health practitioners prefer to use narrative progress notes. These notes provide a more detailed and descriptive account of the therapy session, including the client's presentation, interventions used, responses, and plans for future sessions. Narrative notes may be particularly useful for complex cases or when documenting significant events or breakthroughs.

Why choose Carepatron as your clinical documentation software?

Choosing the right clinical documentation software can significantly impact the quality and efficiency of your healthcare practice. Carepatron stands out as a comprehensive solution that streamlines your mental health documentation process, ensuring accurate and compliant progress notes while saving you valuable time.

Carepatron understands that every practice has unique documentation needs. That's why it offers customizable templates for counseling or psychotherapy notes, including the widely used SOAP format. You can tailor these templates to your specific requirements, ensuring that your documentation captures all the necessary details.

Our software also seamlessly integrates with other healthcare systems and electronic patient records solutions, enabling efficient data sharing and reducing the risk of duplication or errors in documentation.

Ready to join thousands of mental health professionals who already trust Carepatron as their reliable practice management partner? Sign up for a free trial today!

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The Power of Words in Healthcare: A Patient-Friendly Lexicon. Top 10 List #WordsDoMatter Project

By  Sarah Krüg | January 4, 2018 Categories: General

Language has a magical influence on the lives we lead, with an impact on our thoughts, emotions, and/or actions. The words we use are one of the most potent ingredients in the science of language. Words have the power to heal, guide and motivate. They can confuse, mislead, and even hurt us. The intent of a spoken word can often be misinterpreted leading to an unintended consequence. The majority of our words are a result of habit and convenience. If we follow the ripple effect of our words to understand the emotions and/or behaviors they might potentially trigger, would it force us to pause, think and perhaps communicate differently?

There are terms and phrases that those of us who work in healthcare use regularly. Some of these words have been around since the turn of the century…and others are newer and somewhat trendy. In my work with patients and their families, I have found that many would rather us skip some of this terminology in our conversations with them. I’ve captured thousands of terms in my research and I’ve been working with members of the community to identify new terms to consider, which can allow us to redesign the language we use with patients and their families in healthcare. There are words that we might continue to use in exchanges with one another as healthcare professionals, academics, researchers, advocates, etc, but this project was focused on the language we use with patients and their families.

Connection is a conversation between the patient story and the language of medicine. Words have the power to transform healthcare and if you don’t speak their language, they won’t hear you.

Since 2016 when this project launched, 3, 842 words/phrases have been crowd-sourced where we asked “What word(s) should we stop using or limit use of with patients and/or their families? Why?”

The submissions were analyzed and the TOP 10 words are listed here based on the most common words suggested. There are plenty of other words that don’t make sense to patients and their families, but we’ll start with the Top 10 and continue to build on these.

The next steps are to involve the community (YOU) in the “ Words Do Matter” Project with your feedback and suggested alternative terms. We will continue our current participatory co-design work with patients and their families to develop a new set of terms that can be used with patients and families. We will also conduct a few “Man on the Street” interviews to supplement this work. Ultimately, the goal is to develop a patient-friendly lexicon.

Here are the words I vow not to use with patients and their families in 2018! #newyearresolution2018

Top 10 Words (and the most interesting and sometimes humorous explanations as to why!)

• Patient Engagement

The use of this trendy word skyrocketed several years ago and has led to start-ups, tools, apps, workgroups, behavior change strategies, research studies and mission statements (among other things) all focused on this topic, without a consistent definition of what it actually means. No wonder the most popular Google search on this term was “What is Patient Engagement?”

Here’s what a patient had to say which is indicative of how easy words can get lost in translation, “Last I checked, engagement was a formal agreement to get married. How does that apply to healthcare??”

Another patient explained, “ It’s a paternalistic term. If I don’t want to track my symptoms using your app and don’t want a weekly call, does it make me non-engaged? I don’t always want to be reminded that I am sick but I’m managing my health to the best of my ability, while managing life. Why does it have to be one size fits all?”

• Patient Journey

With the prevalence of journey mapping, this term has become widely used in our circles.

As one patient put it, “ A 6 day trip to an exotic place that I’ve happily planned with an origin and destination is a journey. The multiple sclerosis I have or the cancer my husband got a few years ago—that’s not a journey!”

• Patient-Centric

Although the Institute of Medicine defines patient-centered care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions”, many in healthcare have deviated slightly and used this term in different capacities to define strategies now focused on the patient.

“This seems fairly new and I hear it all the time now. What were you focused on before you became patient-centric? It makes me wonder if this is just marketing buzz. Also, if the goal is partnership (and maybe on even terms), shouldn’t I be part of the circle instead of in the middle?”

This term has risen in popularity given the focus on design thinking principles and partnership in healthcare, yet it has left several baffled (and not just patients)!

In a meeting of the minds, a patient advocate said (and I paraphrase here but this led to a roar of laughter and hopefully won’t offend anyone), “We would never use the word co-create with our patients. Let’s co-create! What does that even mean? It almost sounds like procreate.”

• Compliance & Adherence

These two words aren’t new to the “no-no” list, yet many of us continue to use them.

One of the most direct responses as to why we should stop, ”Pick up a dictionary or a thesaurus to see how insulting these terms are! These words are synonymous with OBEDIENT, SUBSERVIENT, SUBMISSIVE, and PASSIVE. Non-adherence is equivalent with delinquency? Aren’t we in the 21 st century?!”

This word isn’t new to controversy either with question on whether it’s cross-culturally acceptable.

“It’s a pessimistic label that forever ties me to a traumatic event in life, “ eloquently explained a patient.

This has been the subject of research projects with reference of war metaphors connected to a feeling of guilt and/or failure.

“I may come out swinging but if I don’t win the fight , did I not fight hard enough? Am I loser?” asked one patient.

This has different meanings in other countries, such as a nanny or au pair.

As one caregiver articulated, “I don’t see myself as a GIVER of care. I’m a wife that’s confused and just trying figure out how to help my husband manage his mental health and my family cope.”

• Shared Decision Making

This is a topic that’s been around for many decades with various models, guidance documents and decision aids introduced over the years. There is still much work required in effective implementation within the average clinical setting (e.g. community practices).

“I understand that patients and families are playing a greater role in their healthcare and ideally there is more exchange and sharing of bi-directional information, but isn’t the final decision made by my wife after we’ve also gotten a second, and maybe even a third opinion, done our research, figured out what insurance is paying, and then figured out what’s best for us right now? It’s ultimately my wife’s decision—not a shared one,” described a caregiver.

     10. Negative

This term has been the source of confusion for quite sometime, yet lives on in healthcare conversations. Healthcare professionals often use this term to describe “normal” but it can lead to a wave of panic until further clarified.

“ When the doctor told me that I had a negative chest x-ray, I was devastated. How would I know that means normal??”

#WordsdoMatter

Please contribute to the Words Do Matter Project and help us shape the overlooked ingredients in healthcare!

What words would you suggest in lieu of these TOP 10? What words would you add to the list?

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Excellent research and top ten list! Agree whole-heartedly that language and sentiment have a profound impact on relationships, especially the lens through which people view healthcare. Many of these terms exist because processes, workflows, innovations, platforms, and ideologies were created without consideration for the patients’ voice, preferences, values, and needs. Recognition of patients and carepartners as valuable and essential stakeholders of the healthcare ecosystem eliminates incorrect notion that patients (and carepartners) are on the periphery, rather than part of the conversation. Here are my thoughts:

1. Patient Engagement: scrutinizes patients with respect to response (or lackethereof) to various initiatives; doesn’t hold poorly designed healthcare system accountable. Indirectly (and incorrectly) assumes patients are not “good”, “disengaged” patients, assigns blame. 2. Patient Journey: better = life/living with [diagnosis] 3. Patient-centered: better = human-centered or relationship-centered 4. Co-create: better to design, develop, and launch with empathy 5. Compliance & Adherence: treatment planning must have consideration for patient values, preferences, needs as well as finances, social determinants of health 6. Survivor: alternatives may include person with no evidence of disease, no active disease; term is alienating to those with advanced/metastatic disease who will never be survivors. 7. Fight: war metaphors are damaging on many levels and contribute to mental and emotional distress, “survivor’s” guilt 8. Caregiver: carries negative sentiment, implies/defines a patient as unable to care for themselves, helpless, loss of independence. Term “carepartner” is more inclusive, spanning sickness and health, signifying a team effort. 9. Shared Decision Making: by including the patient’s values, preferences, and needs during treatment planning discussions, this term will be eliminated. 10. Negative: Words used to convey test results must be conscious of language and health literacy barriers. Simplify: Xray is normal.

Great post. To your list I add but a smattering of words I’ve collected that would seem crystal clear – along with meeting the right ‘criteria’ (one or two syllables, proper reading level etc) and yet still confound when out of context: gait, dressing, negative, positive, static, wound-care, dose, treat. Doing my Health Literacy and End of Life Planning presos and workshops,the range of interpretations gets in the way of meaningful universal understanding of all the words and concepts of this post. Separately: I wonder if anyone else sees the irony in using the word , Lexicon, when referring to Patient-Friendly ;-)

Language does have magical influence. I appreciate Sarah’s post. Let’s pause and break this down. Some of these ten words are names, labels, such as survivor and caregiver. While these aren’t slurs nor do they denote disrespect, they aren’t in and of themselves that descriptive without the story behind them. A person is always more than a label. Actually, I don’t like other people to label me. I’ve been labeled heterosexual, white, retired, disabled, male nurse, patient, caregiver, etc.  Some labels I own, some labels feel limiting to me.  When I’m with other people who share a label I may either feel solidarity or feel my uniqueness. Usually, I spend little time on the label. I’d rather hear stories, share experiences, what worked and what didn’t with the people with whom I’m sharing a label. When people write and use labels about me, I can’t help but think of exceptions. I am not the typical caregiver, male nurse, retired person.  I guess.

Compliance, adherence, patient-centric, and shared decision-making have a power component. Who’s up, who’s down? As a patient activist, I would rather use Informed Decision-making or Health Care Choices than Shared Decision-making. But depending on the setting and my goals in the interaction,  I may point out the implications of the word choices or I may not. In any communication, I can choose to focus on the words used and do some education. I could listen and try to understand what the person means by the words being used. If I feel the words are offensive, I could speak up, be silent, or leave the room. Up to me.

Words have history. Patient engagement was once a revolutionary new concept. Now it’s lost its meaning or it could mean so many different things. I’d rather engage in my care, negotiate engagement, or find a common meaning with the people I’m in the room with. I think there could be other words used. However, those new words will inevitably become diluted as well.  I use journey a lot. I get so frustrated with the episodic view of health care: the visit, the hospital stay, the diagnosis. I prefer the journey, the adventure, the extended time, people, settings and the idea of a destination or goal. But I don’t care what words other people use, as long as it’s not based on diagnosis and episode.  I’ll keep using journey.

Words are important.  Especially if they’re offensive or as dilute as water. But they are also opportunities for sharing, learning, advocacy. I feel very strongly that refining words used is only step one in activism. More important to me is best health and quality of life; equity; personal, spiritual, food, and financial safety; respect; and community. And what do these words even mean? We listen, talk, and do. Hopefully, communication leads to action – action that we desire. The patient-friendly lexicon will always be dynamic.  Participatory Medicine is part of today’s lexicon.  I’d welcome the day when it gets added to the list as outdated and dilute.

Very much agree Danny. Words do not exist in a vacuum, but are given meaning by the participants in the conversation/interaction and by the words they sit next to. Replacing one term with another supposes that there ARE terms that contain meanings that are independent of context, culture, connotation.

As neither patient or working in the health/care sector, I’m always puzzled by the term co-production. To me it is associated with theatre or more likely television as in the credits for Mrs. Brown’s Boys.

So what on earth provoked a comment here, if you’re not in healthcare? :-) (Can’t help but wonder!)

Is anyone aware of the deadline for the IR Global Training Contract Application? Happy Holidays and many thanks for your friendship and support

Words are seeds that accomplish more than blow around. They land in our souls and not the ground. Be cautious what you plant and cautious what you say. You could need to eat what you established one day.

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Presenting a Patient or Client to the Medical Team

Medical Team

By: Judith P. Bradley, CSW

Aside from clinical training and experience, the one skill a clinician must develop is that of communication. That sounds simple enough—talking and hearing. These abilities are not enough. Let’s look at the ability to LISTEN with purpose and SPEAK with intent. These skills will serve you and the recipient of your services well. The cornerstone of human service is the exchange of information, whether hard data or the interchange of clinical thought. I will address one area of the clinical process, and that is the presentation of a client to colleagues.

    Your information must be relevant and presented in an organized and succinct manner. You must have a template, either in an agency approved written format or your own “cheat sheet.” In some cases, with years of experience, the format can be in your head. I do not recommend it. If you overlook pertinent information, it may get lost in the process. Train yourself from the beginning to be thorough. Over-confidence at any stage in your career can lead to a poor outcome. I recommend that you begin to study and learn your contact forms and use them wisely. Take your own ancillary notes if you must, but the information incorporated into your agency notes must be accurate and appropriate. This will be your guide for presentation.

    The presentation itself can feel daunting. It does not have to be. Once you have your pertinent written data, you must then use the skill of speaking with intent. If you are “all over the place,” the clinical picture of your client will be lost in words. Over time, I learned to use the following format when speaking:

• Objective assessment of client at initial presentation (what I see)
• Client’s assessment of self and presenting problem (what I hear)
• Pertinent bio/psycho/social data (information I collect)
• Collateral information, if taken (from whom and in what context)
• Clinical impression, if appropriate in agency (what I determine thus far)
• Initial disposition of client, including colleagues consulted (what I did)

    The content of the above likely does not include exact information you need to present, unless you are in the behavioral health setting. Nonetheless, there will be necessary data you must impart to serve your client. You may use the above as a guide to organize and train your own mind to consistent gathering of information.

    Now let us look at presentations I have heard in real clinical settings. The clients are real but, of course, with no identifying information.

     She came to the ER last night and uh said she had been feeling depressed and um her husband was with her and said she had been acting different for a while and um he asked her if she thought she needed help and she said yes so he um brought her to the ER. She looked depressed so I told her to make an appointment with the clinic.

    He called and said he wanted help with his drinking problem and we had a detox bed and the physician said okay, let’s admit him, so we did.

    At a shift change: What can I say about him, he is as crazy as ever. (Rolling of the eyes.) His meds were given and he went to bed and slept the whole shift.

    While working inpatient in an adolescent mental health facility, I began realizing that all shift notes were “canned,” and at shift end, many reports were identical or similar. They went something like this: Patient participated in group activities. Worked well with peers. No complaints reported. This is an example of filling in the blanks in order to get a paycheck. Who was the loser in this game?

    These are extreme but, unfortunately, common examples. I once read an emergency contact sheet written by a psychologist who was moonlighting at a community hospital. The demographics were incomplete, and the only other written information on the contact form was “depressed, will make a clinic appointment.” On the night shift at a mental health walk-in clinic, I sat in on a presentation at which the physician had to ask the clinician six times to go to the lobby and get basic history from the client. At what point were any of the above examples serving the client? None.

    Please carefully read the following presentation.

    Patient is a 54 y.o. married white female who presented to the Emergency Department at 11:05 p.m. complaining of being “too depressed to sleep” X2 weeks. She presents as unkempt, thin, tearful at times, withdrawn as evidenced by dropping of the head and little eye contact. She gives a complete history with some prompting. Her thought process and content are normal. Some psychomotor retardation is noted, as evidenced by slowing of verbal responses and motor movement. Her affect was congruent with mood described. She denied suicidal intent and homicidal ideation but states, “If I could sleep, I don’t care if I don’t wake up.” She reports the duration of the symptom X2 weeks as well as feeling tired X “about a year.” She denies any other psychiatric symptoms. The precipitant to this visit was, “I can’t go another night like this.”

    She has been married to her current spouse X 30 years with two adult children. She reports no history of psychiatric treatment, no psychogenic medications. She does report a history of mom suffering from depression following menopause in her mid-fifties. Mom’s medical doctor treated her with tri-cyclic antidepressant meds, but she remained dysthymic until her death at age 79. She knows of no other familial psychiatric history. Patient is status/post colon resection due to diverticulitis X 8 months ago by Dr. N. with good results. She reports her symptoms have increased slightly since the surgery. Her primary physician is Dr. B., whom she has not consulted. The patient states that menses is slight and irregular X 2 years, and she has not seen a gynecologist X3 years. She is currently taking meds for increased cholesterol and denies any alcohol, drug, or tobacco use.

    I conducted a collateral interview with patient’s husband, and he concurred with patient's presentation and only disagrees with the duration of the depressive symptoms. He reports that she has had trouble sleeping for 2-3 months, as well as intermittent tearfulness, and decreased activity and anhedonia X “a couple of years.” He presents as a responsible adult, loving and caring toward the patient, but frustrated that “he can’t do anything to help her.” She has refused to get prior treatment because “she doesn’t want to be like her mother.”

    I consulted with ER staff physician Dr. L., who examined the patient and gave medical clearance. Dr. P., psychiatrist on-call, was contacted and agreed to admit the patient to the Behavioral Health Unit for observation and treatment. Any questions?

    Now, let us dissect the above presentation. Do not be distracted by the clinical information, as your agency and your job responsibilities may require completely different data. Let us just look at the manner in which the information was presented, not the content. Keep in mind some buzzwords: succinct, organized, purposeful, and relevant.

    Succinct describes a statement that is to the point with no superfluous verbiage. Let us take, for example “normal thought content.” That phrase rules out a litany of psychiatric symptoms. Keep your descriptive words to a minimum, unless they are pertinent. Never, never attach motive. I have heard many times the phrases, “She just needs to leave him,” or “He just needs to get a life.” Also, unless diagnosed properly, never assume a client’s underlying problem, such as, “I’ll bet she was abused,” or “Those kids need to be taken away,” or, “She is just staying with him for the money,” or the all-time favorite, “She’s just borderline” (meaning Borderline Personality Disorder).

    We all know what organization means. How many of us really are organized? In a presentation setting, organization is crucial. The time to implement your organization plan is when you sit down with the client, not when you are faced with a presentation or written notes. Know what you are going after, keep the client on task, and forge ahead. It is natural for a client to start talking. You may be the only person who will listen. This will likely come in disjointed spurts of verbiage. That is understandable. If there were neither dysfunction nor serious need, you would not be having the conversation. Your organizational skills will bring the client back. You may need to use gentle nudging or skills that require more assertiveness. I have found the following phrases helpful:

• Tell me more about your family history.
• You were telling me a moment ago about _________. May we finish talking about that?
• You know, Mrs. N., we are going to want to talk about that later, but right now I need to ask some questions so we can hurry and get you started.

    Unanswered questions need to be documented as, “Client either unwilling or unable to answer the question,” or “Client is poor historian.” Never leave a blank. The fact that the question went unanswered could be clinically relevant. It could speak volumes.

    Ask purposeful questions. You are the organizer. For instance, has the client been ill recently? If yes, then when, what, duration, treatment, family history, status. Do not allow the client to begin with a narration of the course of the illness, including how many stitches he or she had and whether or not the neighbors helped. Purposeful may sound sterile and clinical. Thus, you must have a trusting rapport with the client. If you speak in clear non-clinical terms, the client will feel comfortable. If you blast the client with big words and even bigger ego, the client is likely to neither trust nor utilize your agency. This is the worst outcome possible.

    This takes us to relevancy. You are in control, you are the organizer, and you are responsible for the information, which will take this client into the next crucial phase of treatment. You are the gatekeeper. Generally, a client will continue to talk and emote. Listen intently and glean relevant information. The client cannot be allowed to talk indefinitely, as there are time constraints. Nor is it helpful for a client to complain without end. Remember boundaries. However, many times while answering questions or explaining dilemmas, you will glean pertinent data. So listen with purpose. Your purpose should be clear by now. You will be ushering this human being into a team of professionals who will, in no small part, help determine the outcome of his or her future.

    In conclusion, the information you collect and subsequently pass off in the process is crucial. I cannot say that missed information will sabotage a client’s treatment, but it can certainly hold it up. It could take time for information to surface again. Thus, I reiterate: Listen with purpose and speak with intent. It is simply a matter of knowing what you need and gleaning it with respect, reporting it in an organized and succinct manner, while treating your client and colleagues professionally.

    So, remember the following:

Organization starts before your contact with the client.

• Gather your information in a non-sterile manner.
• Be thorough and focused. Remember what information you need.
• If the above is accomplished, you will be prepared for your presentation with the help of an organizational tool.
• Your focus in presentation is to pass on relevant data in order for the process to continue seamlessly.
• Use intent in speaking without irrelevant verbiage. You must stay focused and keep your colleagues on task. They will wander.
• Be succinct and concise. If information is missing or sketchy, report the reason.
• Always end with “Any questions?” or “Are there questions?”
• Do not be intimidated. You are prepared. It becomes second nature with practice.
• Graciously accept and learn from feedback. It is the professional way!

Judith P. Bradley, CSW, practiced for many years in the field of behavioral health and crisis intervention. She has retired to coastal North Carolina, where she will soon begin consulting.

This article is from the Spring 2010 issue of THE NEW SOCIAL WORKER. Copyright 2010 White Hat Communications. All rights reserved.

All material published on this website Copyright 1994-2023 White Hat Communications. All rights reserved. Please contact the publisher for permission to reproduce or reprint any materials on this site. Opinions expressed on this site are the opinions of the writer and do not necessarily represent the views of the publisher. As an Amazon Associate, we earn from qualifying purchases.

• Last edited on January 18, 2024

Mental Status Exam (MSE)

Table of contents, appearance and behaviour, thought content, thought form/process.

The Mental Status Exam (MSE) is a systematic way of describing a patient's mental state at the time you were doing a psychiatric assessment. An observant clinician can do a comprehensive mental status exam that helps guide them towards a diagnosis.

• A - Appearance/Behaviour
• E - Emotion (Mood and Affect)
• P - Perception (Auditory/Visual Hallucinations)
• T - Thought Content (Suicidal/Homicidal Ideation) and Process
• I - Insight and Judgement
• C - Cognition

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Why Write Down a Mental Status Exam Over and Over Again?

• Look for any unusual movements : gait abnormalities , tics , psychomotor agitation or retardation, tremor (at rest or with movement), and signs of extrapyramidal symptoms due to medications.
• Note the posture, clothes, grooming, and cleanliness
• Make note of any evidence of self-harm (cuts on wrists/legs), significant weight loss or cachexia (think anorexia ), or signs of physical injury (think domestic abuse, or involvement in violent situations)
• Note any mannerisms, gestures, expression, eye contact, ability to follow commands/requests, compulsions
• Note if the patient is cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, or defensive
• Is the patient vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating
• You may need to do further cognitive testing if there is concern (see Cognition section below)
• “What is your full name?”
• “Where are we at (floor, building, city, county, and state)?”
• “What is the full date today (date, month, year, day of the week, and season of the year)?”
• Is the rapport good, fair, or bad?
• Does the patient trust you and do you have a good connection/relationship?
• Talkative, spontaneous, expansive, paucity, poverty of speech (i.e. - very little is said)
• Fast, slow, normal, pressured
• Loud, soft, monotone, weak, strong
• Slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic
• How long does it take the patient to respond?
• Emotion consists of mood and affect .
• Ask the patient: “How are you feeling?” or “How is your mood?”
• Note the appropriateness of the patient's affect to the current situation
• Fluctuations in affect : labile, even, expansive
• Range of affect : broad, restricted
• Intensity of affect : blunted, flat, normal, hyper-energized
• Quality of affect : sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable
• Is there congruency between mood and affect? (i.e. - they say they are sad, but are laughing)
• Is there congruency between thought content and affect? (i.e. - they look sad, but say “I feel happy.”)
• Illusions are non-pathologic – most individuals can point to a time when they had a misperception or fleeting perception (e.g. - thinking hearing one's name called when no one else is home, or thinking there is someone hiding in the dark at night).
• Does the patient hear one or several voices?
• Are the voices male or female?
• Are the voices or people they know or are they unfamiliar?
• Are these voices simple statements, or complex sentences?
• Do the voices engage in a conversation with the patient or comment on the patient’s thoughts?
• Command auditory hallucinations (i.e. - voices instructing the patient do to things) are frequently considered a concerning feature of psychosis that requires inpatient hospitalization.
• Auditory hallucinations are the most common type of hallucination in non-organic (i.e. - primary) psychiatric conditions
• Visual hallucinations should prompt a more detailed neurologic history and exam !
• Migraines are the most common single cause of visual hallucinations and illusions.
• Visual phenonemona (e.g. - auras from seizures ) can also be reported as visual hallucinations.
• Individuals with Dementia with Lewy Bodies may experience visual hallucinations are part of their core symptoms.
• Charles Bonnet Syndrome (CBS) is a common non-psychiatric condition among people with serious vision loss (macular degeneration, glaucoma, and diabetic retinopathy) characterized by temporary visual hallucinations.
• Individuals with narcolepsy may also experience visual hallucinations
• One should also ask if if hallucinations are congruent with any underlying delusions. Hallucinations may be mood congruent (e.g. - a depressed patient hearing a voice chiding her for failure and urging her to commit suicide) and mood incongruent (e.g. - a patient with schizophrenia who despite being quite paranoid hears voices that they find calm and soothing).
• Ask the patient: “Do you ever feel you are not in your own body, or you are looking from the outside in?”
• Perception that one’s surrounding and events are experienced as if the person is detached from them, or that they are distorted, changed, or unreal
• Perception that one is standing outside oneself as a detached observer to surroundings, experiences, and events that occur
• Delusions are fixed, false beliefs. These are unshakable beliefs are held despite evidence against it, and despite the fact that there is no logical support for it.
• Delusions may have erotomanic, grandiose, jealous, persecutory, and/or somatic themes.
• Also consider if there an extensive delusional belief system that supports the delusion (e.g. - patient may have a very intricate and detailed explanation of why they believe they are being targeted)
• Overvalued ideas are an unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. - the person is able to acknowledge the possibility that the belief is false)
• This is the belief that everything one perceives in the world relates to one's own destiny (e.g. - thinking the newspaper or TV is sending messages or hints to them)
• First rank symptoms are a range of schizophrenia symptoms proposed by psychiatrist Kurt Schneider in 1959 (however, the diagnostic specificity and sensitivity of these symptoms is not perfect and cannot be relied on to diagnose schizophrenia alone). [3] First rank symptoms include:
• Hearing thoughts spoken aloud
• Hearing voices referring to himself/herself made in the third person, or
• Auditory hallucinations in the form of a commentary
• A patient's thoughts are under control of an outside agency and can be removed, inserted (and felt to be alien to him/her) or interrupted by others (e.g. - “My thoughts are fine except when the Pope stops them.”)
• The patient is thinking everyone is thinking in unison with him/her (e.g. - “My thoughts filter out of my head and everyone can pick them up if they walk past.”)
• A hallucination involving the perception of a physical experience with the body
• A true perception, to which a person attributes a false meaning (e.g. - traffic lights turning red may be interpreted by the patient as meaning that Martians are about to land)
• Where there is certainty that an action of the person or a feeling is caused not by themselves but by some others or other force (“The FBI, NSA, and CIA controlled my arm.”)
• Ego-dystonic thoughts are thoughts that are not in line with who we are and/or what we believe (i.e. - the thoughts of hurting themselves (suicide) or others (homicide) may be very distressing to the patient)
• Ego-syntonic thoguhts refers to instincts or ideas that are acceptable to the self; that are compatible with one's values and ways of thinking.
• The individual's ideas string together in a relatively linear fashion, and obeys the conventions of grammar and syntax.
• Over-inclusion of trivial or irrelevant details that impede the sense of getting to the point. Patients will often get back to the original point or question you asked, may wander and be over-inclusive.
• The patient provides an answer to a question that veers off from the target of the question, but the connection may still be appreciated or inferred by the clinician.
• Coherence is the orderly flow of information when speaking, and how well words, sentences, and overall speech is connected.
• Incoherence is an overall descriptor. If someone is incoherent, they may be mumbling, have loose associations, be tangential, or otherwise have some kind of thought disorder.
• Rapid jumping (“flight”) from topic to topic without completing each train of thought (usually occurs during a manic episode )
• Loss of the goal of a communication and not being able to return to the topic
• Persistent inappropriate repetition of same thoughts (e.g. - saying “I'm dead. I'm dead. I'm dead.”)
• A word created by the patient that does not have any meaning to others (e.g. - “cranium sock” to mean hat)
• A breakdown in both the logical connection between ideas/words and the overall sense of goal-directedness. The words make sentences, but the sentences do not make sense!
• Clang associations is one type of loose association where words that sound alike are lumped together. [4]
• A confused or unintelligible mixture of seemingly random words and phrases
• Mini-Mental Status Exam (MMSE)
• Montreal Cognitive Assessment (MoCA)
• Frontal Assessment Battery (FAB)
• Ask also about education level to get a sense of what the person's baseline cognition and intellectual function may be.
• What is the patient's understanding of the world around them and their illness?
• Are they able to reality test? (i.e. - are they able to see the situation as it really is?)
• Are they help-seeking? Help-rejecting?
• Poor (patient may be in complete denial of their symptoms or diagnosis, or there may be some slight awareness)
• The patient may understand their symptoms or diagnosis intellectual “on paper,” but fail to understand it emotionally, or fully grasp the impact of it on their life
• Overall, a good intellectual and emotional understanding of their symptoms or difficulties. Patient is acutely aware of their symptoms or illness, and also of their own limitations and strengths. Their symptoms are likely to be in remission, and they know when to reach out for help and when to rely on themselves.
• Insight does not mean agreeing with the doctor! [5]

Anosognosia

• What have the patient's recent actions been?
• Have they done anything to put themselves or other people at harm?
• Are they behaving in a way that is motivated by perceptual disturbances or paranoia?
• What is your confidence in the patient's decision making?
• Impaired (for individuals who are acutely intoxicated)
• Poor (in the context of acute psychosis in schizophrenia or dementia)
• Good (patient is aware and makes decisions in a way that does not put them or others in harm)
• Keep in mind there is no formal way of describing judgment, and even the descriptors may vary among clinicians
• Toronto Hub: MSE

A safe place to talk openly about mental health & illness

A Glossary of Psychiatric Terms

Like any field, psychiatry has its own collection of terminology. Some of it is self-explanatory, but some of it isn’t. I believe that knowing the jargon helps to narrow the power gap between health care providers and patients, so I put together this glossary of common psychiatric terms.

Table of Contents

Words to describe affect, changes in movement, disturbances in speech, suicidal ideation, types of hallucinations, thought form/thought process, passing judgment.

• Alexithymia : an inability to identify and describe one’s emotions; considered to be a personality trait
• Anhedonia : an inability to experience pleasure
• Anosognosia : lack of insight into one’s own illness and its effects (this isn’t disagreeing with one’s diagnosis, but rather a lack of self-awareness); anosognosia is often a symptom of illness
• Avolition : an inability to initiate and persist in goal-directed activities
• Confabulation : This is the unconscious filling in of memory gaps by imagined events that doesn’t involve intentional lying. It can be caused by traumatic brain injury.
• Depersonalization : a form of dissociation in which the self doesn’t feel real, which may include a feeling of looking at the self from a detached perspective
• Derealization : also a form of dissociation, this involves a sense that one’s surroundings aren’t fully real, and may feel like looking out at the world through a barrier
• Ego-dystonic : thoughts that are unwanted and inconsistent with what someone normally believes when they are well (the opposite of this is ego-syntonic); for example, OCD obsessions about being a risk to harm someone else would likely be ego-dystonic, while OCPD obsessiveness may be related to an ego-syntonic desire for perfection

The term affect refers to the facial expression of emotions.

• Euthymic : neutral, “normal”
• Expansive : unrestrained expression of feelings
• Incongruent : doesn’t match the reported mood, e.g. smiling while reporting feeling sad
• Labile : rapidly changing from one emotion to another, such as crying one minute and smiling brightly the next
• Restricted/blunted/flat : These all refer to decreased facial expressiveness. Restricted is the mildest term, and flat refers to almost no emotional expression.
• Stupor : lack of psychomotor activity, unreactive to the environment
• Catalepsy : fixed, rigid posture held against gravity
• Waxy flexibility : allows limbs to be moved into positions, and then holds them there
• Mutism : lack of verbal responsiveness
• Negativism : does not respond to instructions, and may actively oppose attempts to be moved
• Echopraxia : imitation of movements; can be part of catatonia
• Psychomotor agitation : unintentional, purposeless movement, such as hand wringing or pacing
• Psychomotor retardation : slowing of thoughts and movement that can be seen in major depressive episodes (I’ve made a Youtube video demonstrating this)
• Alogia : lack of speech, implying impoverished thinking; can involve a decreased amount of speech production (may be referred to as poverty of speech) or a lack of content (may be referred to as poverty of thought)
• Dysprosody : abnormal rhythm of speech
• Echolalia : imitation of words/sounds
• Logorrhea (voluble speech): excessive amounts of speech; a similar colloquial term would be verbal diarrhea
• Pressured speech : speech that is very rapid and difficult to interrupt; a common symptom in mania

Suicidal ideation (SI) refers to thoughts of suicide . It’s typically referred to as suicidal ideation (as in suicidal thinking) rather than suicidal ideations (as in suicidal thoughts).

• Active : thoughts of acting to take one’s life; may or may not have a specific plan, and the intent to act on those thoughts can be variable
• Passive : wishing to die, but not thinking about doing something to make that happen

Delusions are fixed beliefs that can’t be budged with evidence to the contrary, that are not accounted for by culturally accepted beliefs and interfere with one’s ability to interact with reality. Simply believing something that isn’t true isn’t a delusion.

There’s more on this topic in the post Common Themes of Delusions in Psychosis .

Types of delusions

• Capgras : believing that people have been replaced by imposters
• Thought broadcasting : believing that one’s thoughts can be heard by other people
• Thought insertion/thought withdrawal : believing that thoughts are being put into or taken out of one’s head
• Erotomanic : believing that one is in a romantic relationship that doesn’t actually exist, often with a famous person
• Grandiose : an inflated self, abilities, and connections that reaches delusional proportions, such as the belief that one is a key advisor to a major political figure. It can be important to obtain collateral to verify whether certain beliefs are actually reality-based, but someone who is delusional about being an important public figure would typically speak differently about it than someone who actually is an important figure. Grandiosity can also be non-delusional, such as in narcissistic personality disorder.
• Ideas of reference : interpreting messages as being particularly directed at oneself, including things on billboards, tv, or radio; for example, something on a news broadcast might be perceived as containing a hidden message directed specifically at the individual.
• Paranoid/persecutory : This is probably what first comes to mind when many people think of delusions, and involves a belief that one will be harmed. These delusions may be further described as non-bizarre (within the realm of possibility, like being monitored by the government) or bizarre (aliens trying to enter their home via the cat door to steal their right foot). Paranoia can also occur in a non-delusional sense.
• Religious : religious delusions, such as believing that one is Jesus, that are a departure from an individual’s beliefs when non-psychotic, and are not in keeping with the accepted beliefs of their religious community; someone who is religious at baseline may become hyper-religious when unwell, which my involve delusional interpretations of elements of their religion
• Somatic : false beliefs about things that are happening in one’s body, ranging from something non-bizarre like cancer to something bizarre, like believing one’s stomach is filled with dancing turtles

Describing delusions

• Bizarre/non-bizarre : Bizarre delusions are very removed from the realm of possibility, such as aliens entering one’s home every night through the water pipes and removing one’s toes to implant them in one’s brain. Non-bizarre delusions are within the realm of possibilities, such as the government watching one’s every move, but the individual’s relationship with that belief is still delusional.
• Delusional proportions : this refers to experiences, such as guilt or obsessions, that may be or may have been experienced non-psychotically, but they have intensified enough that they have reached the strength of delusions
• Mood-congruent : people experiencing mood episodes may experience delusions that match their mood, such as delusions of guilt during a depressive episode or grandiose delusions during a manic episode
• Overvalued ideas : these are beliefs that someone is quite fixed on, but not to the extent that are delusional
• Auditory (AH) : hallucinations involving sound — may be voices or other sounds, familiar or unfamiliar voices, and single voices at a time or more than one voice conversing
• Gustatory : hallucinations involving taste
• Olfactory : hallucinations involving odours
• Tactile : hallucinations involving the sense of touch, such as bugs crawling on the skin
• Visual (VH) : “seeing things”; these are less common than auditory hallucinations, and may be indicative of a physical (“organic”) problem within the brain
• Hypnogogic : these occur while during the transition from awake to sleep, and aren’t considered psychotic in nature
• Hypnopompic : these are similar to hypnogogic hallucinations, but happen while waking; again, these are considered normal rather than psychotic
• Command hallucinations : these are hallucinations that instruct people to perform certain acts, which may involve harming the self or others
• Responding to internal stimuli : This is sometimes used to describe someone who appears to be responding to hallucinations, such as if they appear to be listening to auditory hallucinations or talking back to them. They’re internal stimuli in the sense that they’re coming from within the mind rather than coming from the external environment via the senses. While many people talk to themselves, listening to someone who’s responding to internal stimuli sounds like you’re hearing only half of a conversation.
• Circumstantiality : wandering away from the original idea, but eventually returning to it; like beating around the bush
• Clanging : grouping unrelated words based on sound (such as rhyming) in a non-meaningful way
• Concrete : This involves very literal interpretation of information, and can be tested by asking a patient to interpret proverbs, e.g. “it ain’t over til the fat lady sings” might be interpreted as an obese woman needing to sing O Sole Mio before something could be considered finished
• Loose associations : connecting ideas that seem to be totally unrelated
• Neologisms : making up new words; in a psychiatric context, this refers specifically to neologisms that arise due to thought disorder rather than intentional coining of new terms
• Overinclusive : including excessive, unnecessary amounts of detail, e.g. “I’m sorry I’m late. I left home on time, and I was driving here in my car—it’s a Toyota Corolla that’s a 2012, but I bought it in 2014, and it’s blue, but there are chips of paint missing where the passenger door has been dented; I really like that it has Bluetooth because it means I can listen to songs from my iPhone. I had my classic rock playlist on while I was coming here, because I like to sing along to ACDC. I parked my car on Laurel Avenue and then I was walking towards your office, but then I couldn’t cross Main St. because a fuel truck had overturned and was on fire, so that’s why I’m late.”
• Perseveration : repeatedly returning to the same topic, and may be veeeeeery difficult to redirect away from that topic
• Poverty of thought : an easy way to describe this might be that the lights are on but nobody’s home
• Tangentiality : going off on a tangent that may be only slightly related, and losing the original idea, never to return to it again; often seen in mania
• Word salad : words put together in a completely incoherent manner, e.g “The purple Christmas fish road living pie.” I’ve seen this term co-opted by the online narcissistic abuse community, but the meaning that’s been assigned to it in that context is not the same as the psychiatric meaning.

Some of these terms may sound rather judge-y, but they’re defined in such a way that they’re intended to be descriptors rather than value judgments. It’s also important to have standardized language in order to avoid confusion from people using different definitions or from vague language. Still, if a patient ends up reading their chart later on, drawing on their familiarity with colloquial usage of psychiatric jargon, it can be easy to infer judgments that aren’t actually present when the language is used in a purely psychiatric sense..

Have you ever had psychiatric jargon applied to you in some way that felt wrong or judgmental?

For a more extensive list of terms, the World Health Organization has a lexicon of psychiatric and mental health terms.

Related posts

• How We Talk About Mental Illness: Definitions vs. Connotations
• Psychosis, Psychopathy & Other Psych Terms
• The Mental Status Exam (MSE) in Psychiatry

Making Sense of Psychiatric Diagnosis aims to cut through the misunderstanding and stigma, drawing on the DSM-5 diagnostic criteria and guest narratives to present mental illness as it really is.

It’s available on Amazon and Google Play .

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23 thoughts on “a glossary of psychiatric terms”.

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