You just saw a new patient – wow, there was a lot going on. The patient described a few new symptoms which you explored in detail. You then followed up on the status of their chronic conditions. A ROS and psychosocial screening raised some more questions. Patient also needed refills, vaccines, and some preventive care. How do you describe this complex event to your clinic preceptor?
The goal of case presentations is to accurately describe an encounter so our colleagues can be fully informed to collaborate in care. SBAP is a outpatient presentation framework structured to help organize raw data, walk through steps in clinical reasoning, and then conceptualize a personalized care plans. Sharing a common format for clinical communication allows colleagues to think through cases together. By understanding your diagnostic path, colleagues and supervisors can be more targetted in their assistance and guidance. SBAP can be followed for both notes and presentations.
Prepare your listener-Explain the context of this interaction, who and why is the patient here today (brief epi, chief concern)? What is the context of this visit- New primary care pt? follow-up? urgent care? Preop consult? What are your needs from the listener- Are you pressed for time? Would you like them to see the pt to confirm an finding? Is there a learning question (advanced learners)?
Now describing who the patient, baseline health/function, and history of present illness. Often we start with prioritized listing of of relevant prior conditions (pmhx). This helps to set the context for the CC and HPI that follows. Sochx/Family hx/medications/allergies are also reviewed. Physical exam and testing results then follow. (Background =SO part of SOAP)
A case summary statement now condenses key data collected into a "one liner". The one liner is your "problem representation", it is a platform to highlight defining case features are pivotal to our decision making. A well written one liner, is informative, concise, and can help quickly get others up to speed. 3 things must be included:
That's it, just2-3 sentences summarizing key facts. Do not debate differentials in the one liner as it is only a summary of the key pieces of the puzzle in the encounter (problem representation). Keep it neutral and avoid turning it into a closing argument for a favored diagnosis, as we may throw out important facts that don't fit
Identify key problems we need to solve on THIS visit. What barriers exist between this pt and wellness? Problem #1 is always the pt's concern. After that, prioritize problems that concern you (both acute and chronic dz). Preventive care is always the last "problem" to consider. The differential diagnosis and plan ONLY discussed as a part of an identified problem. A problem can be biomedical (headache, diabetes), or biopsychosocial (depression, or inability to afford medication). To avoid early closure, you can only define each problem to the highest level of certainty at this very moment (For example "Problem #1 Dyspnea" instead of heart failure, if you are still not sure if copd have been ruled out).