Handout 8

Presenting on morning rounds – check list

Transitions to Inpatient Medicine Clerkship
SOAP: Notes and Presenting on Rounds

□ Go through pre-rounding check list provided in the morning and note any pertinent findings on
vitals, physical exam, and labs/imaging
□ Always make sure to talk to bedside nurse for recap of overnight events and any morning
concerns
□ Start presentation with subjective information:
o Opening statement should have 5 elements – age, race, gender, complaint, and duration
o Discuss any overnight events
o Discuss patient complaints and concerns
□ Move to objective data:
o List out pertinent vital sign findings or give range (discuss with resident/attending their
preference)
§ Ex. “Patient was febrile to 103 overnight with appropriate elevation in HR and
BP at that time.”
§ “Tm 99.6, followed by HR, BP, RR, oxygen saturation ranges”
o Discuss Ins and Outs
§ Ex. “Ins were 1200 cc total, all through IVF, nothing PO.”
§ Ex. “Chest tube output was 350 cc total, compared to 500 cc the day prior.”
§ Ex. “Had 10 stools recorded yesterday, decreased from 15 the day prior.”
o Physical exam should address two things: 1) abnormal findings; 2) address system of
chief complaint
o Present labs/imaging are that new for that day
□ Present your assessment – give a snap shot of what is going on with the patient.
o If known diagnosis, comment on current clinical status (improving, worsening, same)
o If unknown diagnosis, prioritize top three items on your differential diagnosis
□ Wrap up with the plan – ask your resident or attending if should be system based or problem
based
o Be organized and succinct about things you are doing on that day for your patient

Other presentation pearls:

□ Practice, practice, practice
□ Listen to others
□ Keep standard SOAP order
□ Don’t mix subjective and objective
□ Ask your resident/attending how they want you to present – every attending is different and
knowing their expectations will help you do your best
□ Ask for feedback
□ Practice, practice, practice