Inpatient Presentations

By Brandon Rose, MD, MPH

Clinical oral presentations vary based on clinical setting, specialty, attending, and context. Here is a general outline that can help you gather everything you would need to know about a patient. This outline is somewhat parallel to I-PASS, a common menumonic for handing off patients.

Illness Severity - Stable, watch, or unstable - if your patient is not stable they should be discussed sooner

Subjective (History) - varies based on attending familiarity

One liner: age/sex and reason for admission (55 y/o male with KEY HISTORY admitted for TOP PROBLEM)

*Code Status: consider including in one liner if patient is unstable or DNR/DNI

Management-changing updates (s/p thoracentesis): most attendings don't want to wait for important updates

*Full History: choose this if the patient has not been formally presented to the patient yet 

HPI: why did the patient seek medical help (symptoms/OLDCARTS/OPQRST)? What is the larger context of this particular problem?

PMH, PSH, FH, SH, Allergies, Medications (home), ROS (if needed)

*Brief Hospital Course: alternative to full history if there is a new attending and the patient has been admitted for a while.

Subjective Updates (overnight events): the patient's problem-focused symptoms in the context of why they are admitted and any overnight events

Objective (data) - varies based on the attending and your role on the team

Vitals: prefer summary statements for normal (afebrile, non-tachycardic, normotensive) and range values with trends for abnormal

Exam: YOUR exam that you did TODAY

Labs: prefer summary statements for normal (CBC and CMP within normal limits) and exact values with trends for abnormal

Imaging: anything in the 24-48 hours, US, XRAY, CT, MRI

Micro: always double check any pending cultures

Diagnostics/Procedures/Pathology: any surgeries, biopsies, invasive procedures  

Assessment/Plan (medical decision making) - varies based on the attending and your role on the team

Brief overall assessment: what do you think is going on and what are the barriers to discharge? Keep it short.

*Update Summary: for complicated patients, I sometimes highlight recent updates separately in addition to below

Problem(s): be specific as possible, diagnosis with qualifiers > diagnosis >> symptom. Every medication/intervention should have an associated problem

Medical reasoning: your thoughts on what is going on for this problem

Key data: summarized and trending, not verbatim. Biopsy > imaging > labs

Consultant Recommendations: specialists that are following and what they recommended most recently

Plan: all medications and changes

*Discharge Planning: consider including if things need to be coordinated

Other: Diet, DVT prophylaxis, Code Status, Disposition (intended DC date)

Handoffs Tools (more to come later)

SBAR (Wikipedia Page)






Illness severity 

Patient summary 

Action list 

Situation awareness and contingency planning 

Synthesis by receiver