College of Nursing

CASE PRESENTATION FORMAT
(GENERAL WARD)

I. Introduction

II. Purpose/Objective

- Learning a skill that you will use for your entire career -- and that skill is to be able to communicate in a way that enables you to present the patient to any other health-care provider in a concise manner.  It is like learning another language.

|LEARNING GOAL |STUDENT CENTERED |CLIENT CENTERED | |SKILLS | | | |KNOWLEDGE | | | |ATTITUDE | | |

III. 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 IV. History of Present Illness (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 ...

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