Outpatient OCPs

For acute problems and chronic disease management, the OCP will be presented in the same format as the SOAP note, aiming for 3-5 minutes long.  Review the previous chapter on how to document acute, chronic and preventive health (wellness visits). Utilize these same approaches for your oral case presentation.

  • Subjective: ID/CC, what the patient tells you, organized by problem if more than one problem is addressed
  • Objective:  vital signs, physical exam, labs and imaging
  • Assessment & plan: you should always include an attempt at formulating an assessment and plan, even if you’ve only had a minute or two to pull your thoughts together

It is a good practice to share your clinical reasoning verbally even if you have not come up with a final assessment or plan.  This helps your preceptor know what you are thinking and provides them the opportunity to give specific guidance and education.

Consider ending your oral case presentation with a ‘learning question’ to guide your preceptor’s teaching:

“My learning question is…

Will you confirm the lung exam with me?

How would I differentiate bronchitis from a URI?”

Under what circumstances would we send someone with a head injury to the ER?”

The following video by Dr. Natalia Filipek (3rd year Internal Medicine resident) is an example of an outpatient oral case presentation that address an acute problem, a chronic medical condition and some preventive health.

 

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The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.