In addition to standard presentation elements, residents MUST PRESENT and highlight these elements verbally to the preceptor:
- All vital signs, including fetal heart tones/rate in OB, or chart open during presentation
- Abnormal physical exam findings or new abnormal diagnostic findings (ECG, rads, etc.)
- High risk conditions or high-risk medications – i.e., anticoagulation, active immunosuppression, complex cardiac history, HIV, congenital anomalies or failure to thrive in peds, concern for self or other harm
Reflect with every patient encounter:
- Are there any red flags?
- Has the worst case been ruled out?
- What doesn’t fit?
- What serious diagnosis could be missed?