A Complete Summary of the Oral Case Presentation

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General Tips
Internal Medicine
Surgery
OBGYN
Psychiatry
Neurology
Pediatrics
Family Medicine
Conclusion

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Key Takeaways:

Mastering the Oral Case Presentation (OCP) is essential for clinical rotations – A well-structured and concise OCP demonstrates your medical knowledge and helps you stand out to attendings.

OCPs follow a structured format but vary by specialty and setting – While SOAP (Subjective, Objective, Assessment, Plan) is a solid foundation, each rotation has unique expectations, from internal medicine’s detailed approach to surgery’s concise style.

Practice, preparation, and adaptability are key – Using templates, refining note-taking strategies, and adjusting to different attendings’ preferences will help you deliver clear, confident presentations.

 

If you’re starting your clerkships for the first time, welcome and congratulations! If not—keep reading anyway! This post will provide a broad overview of each core clinical rotation’s oral case presentation (OCP), which is a concise, structured summary of a patient’s case that communicates key clinical information to your medical team.The OCP is one of the most fundamental ways for a medical student to demonstrate what they know and impress attendings, so it’s vital that you nail it. A great OCP will go a long way in the minds (and hearts) of your audience.

 

 

General Tips

OCP = public speaking (sorry!)

There’s no way around this fact—you’ll be presenting to an audience of anywhere from 1 to 20 people. It may take some time to get used to, but here are some ways to be ready for game day:

1. Start off by having a template or guide in front of you to follow throughout your presentation. This will ensure that everything is in the right order and that you won’t get lost. As you gain more confidence, you may find yourself using your template less and less (at least that’s the goal!).
2. Prepare the components of your presentation that you can the night before. This includes noting specific physical exam maneuvers or findings you want to check in the morning, highlighting any new lab results that may have come in overnight, and more.

SOAP to start

The SOAP (Subjective, Objective, Assessment, Plan) format is a great place to start. It ensures that you cover the four main components of any comprehensive OCP in any specialty, as they all generally follow this format.

The differences and variations lie in the specific history typically reported in a specialty’s OCP, the specialized physical exam findings crucial to that specialty, and the overall level of detail expected (which will be broadly covered below—so keep reading!).

Variety of practice settings within specialties

Even within the specialties themselves, there exists a wide variety of practice settings. From clinics and hospital wards to the ER, consult services, and admitting services, the details of your OCP (though not necessarily the overall SOAP structure) will need to adapt to the specific situation at hand.

For example, family medicine has a strong outpatient component. However, there also exists an inpatient component, as family medicine physicians may manage patients in hospital wards. This can vary depending on the institution where you rotate. Recognizing the specific setting you’re in will help frame the details you need to share about the patient and adhere to any existing conventions.

Some settings, such as the clinic, don’t keep track of I/Os (i.e. “ins and outs”--- a patient’s fluid intake and output), so that part of the presentation would not be shared. Overnight events would not be reported for an outpatient internal medicine rotation, where you’re seeing patients in the clinic. Be sure to recognize the specific practice setting within your rotation and gradually tailor the details of your presentation accordingly.

Clinical Call-Out:
This philosophy also exists for the different types of patient visits you will encounter! Some of them will require you to come up with a diagnosis. Others are just check-in/return visits to monitor progress.

Example:
Third-trimester prenatal care visit? There won't really be a specific "diagnosis" you are trying to nail, so your assessment and plan would be centered instead around how you think the patient is doing and any adjustments to their care plan moving forward.

 

Different attendings, different styles

One of the difficult, yet necessary, realities of being a medical student is that you will have to adapt to the various styles, expectations, and preferences of the different attendings you will work with. Some want all the vital sign numbers read, while others think it’s a waste of time. Some always want the social history reported, while others don’t care unless it is clearly pertinent.

A good way to prepare and adjust to this reality is to have a quick conversation with a new attending you’ve been assigned to work with, and ask them about their expectations for medical student OCPs. If you’re unable to have this conversation beforehand, default to being comprehensive and thorough with all the details, then adjust based on their feedback.

Note-taking strategies

As a medical student, you will want to have some sort of system ready when you present your OCP, allowing you to store your patient data and keep things organized.

As mentioned earlier, a template is useful to keep everything organized so that you’re not fumbling on game day. In addition to a premade template, some students opt to write their notes directly on the patient list that gets printed every morning. Others prefer blank printer paper and freestyle their notes, while some use notebooks with a pre-printed OCP structure purchased online. Experiment to find what works best for you!

Practice, practice, practice

As with most things in life, practice makes perfect. Here are some ways to get your reps in—outside of the time you spend presenting your OCPs on rounds, of course.

• Go on YouTube and look up some example OCPs from various institutions to see the different presentation styles that exist! While they may vary in delivery, they all follow the same general structure and agenda. Take note of the details shared, the language used when reporting findings, and the order in which information is presented.
• As tough as this may be, recording yourself practicing your OCPs is a great way to track your progress and notice the changes that need to be made.

Internal Medicine

The internal medicine (IM) OCP is by far the longest and most thorough OCP that you will have to give. This is because IM covers the diagnosis, treatment, and prevention of a broad spectrum of diseases in adults, making it foundational and general in its scope of practice and knowledge. You’re managing things like electrolyte and fluid imbalances, congestive heart failure, COPD, CKD, and ulcerative colitis… sometimes all in one patient! If you can nail this OCP, you can do any specialty’s OCP.

Subjective

• Identification/Chief Complaint (ID/CC)
  • “One-liner” that succinctly covers the patient’s name, highly relevant subjective patient data, and the nature of their chief complaint
• Overnight Events
  • Notable events to report are ones that would be important for the team to know and would impact the care of that patient for the day (you have to use your judgement on this one!). 
  • If you’re admitting a patient (from the ED, from another unit, etc.), skip this.
• History
  • Interval history for the day for hospitalized patients
  • History of present illness for new admits
• Past Medical History (new admits only)
  • Present the active medical problems that are pertinent to evaluation and ongoing management
• Family Medical History (new admits only)
  • Gather and present the family medical history that you determine to be relevant to the patient’s care
• Past Surgical History (new admits only)
  • Present the patient’s prior surgical procedures that are pertinent to evaluation and ongoing management
• Medications and Allergies (new admits only)
  • Include doses for each medication the patient takes at home and how often they take them (also, be sure to ask how often they miss doses!!!)
    • Distinguish between in-patient medications and home medications
  • For allergies, ask what kind of allergic reaction they have to the med/food
• Health-Related Behaviors (new admits only)
  • Report additional health-related behaviors (substance use, alcohol use, etc.) that have not already been mentioned in the HPI
• Social History (new admits only)
  • Summarize the patient’s living situation, support systems, occupation, identity, and any social issues that could impact their care
• Review of Systems
  • Only present the pertinent positives for the OCP

Objective

• Vitals
  • Also include patient’s weight (kg) if newly admitted
• Ins and Outs (I/Os)
  • Report total fluids in, out, and the net amount, all within the past 24 hours (mL)
• Physical Exam
  • Present physical examination findings that are pertinent to the patient’s hospitalization
  • Always report abnormal findings regardless of organ system
• Labs
  • Report the values of all abnormal lab findings
• Imaging
  • Report any new imaging results, stating what imaging study was done (e.g., CXR, CT AP, MRI of the L ankle, etc.) and the findings/impression of the films
• Other Diagnostics
  • This includes tests such as microbiology tests (e.g., Respiratory viral panel), pathology (e.g., Examining a biopsy), and certain procedures (e.g., Colonoscopy results)

Assessment

• Summary Statement
  • Re-state ID/CC from beginning of the presentation
  • “... found to have ____”
  • “... concerning for ___”
• Problem List
  • Your differential diagnosis with your arguments for and against each diagnosis listed using the patient’s history, physical exam findings, and other available data
• NOTE: If this is instead a return or check-in visit for an otherwise stable condition, then you would instead give your interpretation of the patient’s progress

Plan

• Your proposed plan for each problem listed above
• Usually problem-based on regular medicine floors and systems-based in the ICU
  • Be sure to talk about any medications to start/resume/stop (with method of administration), labs/imaging/other diagnostics to order, bedside procedures to perform (e.g., dressing changes), consults to call, etc.
  • Disposition (aka the destination the patient will be discharged to after their hospitalization) and discharge criteria are also important to talk about
    
    

Surgery

As far as OCPs go, this is one of—if not the shortest—presentations that you’ll have to give. Surgeons don’t have time to stand around and listen to long presentations! Just kidding (kind of). In all seriousness, the OCP you’ll be giving during your surgery rotation will be concise, straight to the point, and not nearly as thorough as the ones you would give in internal medicine, for example. This is because the surgery OCP prioritizes patient information that will best dictate how the surgical procedure will be performed. Key details include the patient's immediate medical indication for surgery, highly relevant medical history, vital signs, and other procedure-specific concerns.

Subjective

• Identification/Chief Complaint (ID/CC)
  •  “One-liner” that succinctly covers the patient’s name, highly relevant subjective patient data, the nature of their chief complaint, and if they’re pre- or post-op (and for what procedure!)
• Overnight Events
  • Notable events to report are ones that would be important for the team to know and would impact the care of the patient for that day (you have to use your judgement on this one!)
• History
  • Surgery generally cares whether the patient has…
    • Voided
    • Passed stool
    • Passed flatulence
    • Changes in pain level
    • Any PO intake
    • Ambulated/walked round
    • Issues seen by consulting services (e.g., internal medicine could be managing the patient’s diabetes on the side)
    • Other medical concerns that may have arisen (e.g., fever)

Objective

• Vitals
• I/Os (intake and output)
  • Report total fluids in, out, and the net amount, all within the past 24 hours (mL)
• Physical Exam
  • • This will be for the system relevant to the patient’s surgery (e.g., an abdominal exam for an abdominal surgery patient)
  • If the surgery has already taken place, this patient is a “post-op patient.” Note how the incision sites and drain sites are doing (we want to know this to determine if things are healing properly!)
• Recent and Relevant Lab/Test Results
  • Imaging
  • ECG
  • PFTs
  • etc.

Assessment

• Summary statement
  • Re-state ID/CC from beginning of the presentation
  • “... found to have ____”
  • “... concerning for ___”
• Problem List
  • Your differential diagnosis with your arguments for and against each diagnosis listed using patient’s history, physical exam findings, and other available data
• NOTE: If this is instead a return or check-in visit for an otherwise stable condition, then you would instead give your interpretation of the patient’s progress

Plan

• Usually problem-based on regular surgery floors and systems-based in the surgical ICU (aka the SICU)
  • Be sure to talk about any medications to start/resume/stop (with method of administration), labs/imaging/other diagnostics to order, and bedside procedures to perform (e.g., dressing changes)
  • Disposition (aka the destination the patient will be discharged to after their hospitalization) and discharge criteria are also important to talk about
• If you’re recommending a certain surgical procedure to take place (assuming that this is a patient who hasn’t had surgery yet), then be sure to include the criteria/indications for that procedure and how the patient fits that criteria
• If this is a post-op patient, be sure to emphasize disposition plans (a.k.a. when they will get to go home and under what conditions!)

Obstetrics and Gynecology

The obstetrics and gynecology (OB-GYN) OCP will vary depending on if you are in the labor and delivery unit, the gynecology clinic, etc. However, the structure and overall approach to information gathering remain largely the same across these settings.

Subjective

• ID/CC
  • “One-liner” that succinctly covers the patient’s name, highly relevant subjective patient data, and the nature of their chief complaint
  • In addition, always include your patient’s G#P#s and gestational age (GA)
    • Gravida: Number of times your patient has been pregnant, including the current pregnancy
    • Para: Outcome of births (TPAL is the acronym)
      • T: Term births born  > 37 weeks gestation
      • P: Preterm births born < 37 weeks gestation
      • A: Abortions
      • L: Living children
    • GA: Stated as weeks and days (e.g., 28 weeks, 5 days → said as “28 and 5”)
• Overnight Events
  • Notable events to report are ones that would be important for the team to know and would impact the care of that patient for the day (you have to use your judgement on this one!)
• History
  • • Be sure to ask about…
      • Loss of fluid
      • Vaginal discharge/bleeding
        • When it comes to vaginal bleeding during pregnancy, also ask about when their last sexual intercourse was
      • Increased or decreased fetal movement after ~17 weeks GA
      • Abdominal cramping
    • Depending on what the patient is being seen for (e.g., amenorrhea, second-trimester prenatal care, etc.), also include questions that are tailored to the concern at hand
    • For initial visits, ask about prior pregnancies and their outcomes, including whether past births were delivered vaginally or by cesarean, and any complications that occurred.
    • Also, present any of the patient’s underlying, chronic disorders that may be complicating the pregnancy, if appropriate
    • Knowing their vaccination status, blood type ABO, and Rh are vital throughout their pregnancy

Objective

• Vitals
  • Also include patient’s weight (kg) if newly admitted
• Ins and Outs (I/Os)
  • Report total fluids in, out, and the net amount, all within the past 24 hours (mL)
• Physical Exam
  • Present physical examination findings that are pertinent to the patient’s hospitalization
  • Always report abnormal findings regardless of organ system
• Labs
  • Report the values of all abnormal lab findings
• Imaging
  • Report any new imaging results, stating what imaging study was done (e.g., CXR, CT AP, MRI of the L ankle, etc.) and the findings/impression of the films
• Other Diagnostics
  • • This includes tests such as microbiology tests (e.g., respiratory viral panel), pathology (e.g., biopsy), and certain procedures (e.g., colonoscopy results)
    • Reading fetal heart tracings from fetal heart rate monitoring (cardiotocography) is essential, when such data is provided!

Assessment

• Summary statement
  • Re-state ID/CC from beginning of the presentation
  • “... found to have ____”
  • “... concerning for ___”
• Problem List
  • Your differential diagnosis with your arguments for and against each diagnosis listed using the patient’s history, physical exam findings, and other available data
• NOTE: If this is instead a return or check-in visit for an otherwise stable condition, then you would instead give your interpretation of the patient’s progress

Plan

• Your proposed plan for each problem listed above
• Usually problem-based
  • Be sure to talk about any medications to start/resume/stop (with method of administration), labs/imaging/other diagnostics to order, bedside procedures to perform (e.g., dressing changes), consults to call, etc.
  • Disposition (aka the destination the patient will be discharged to after their hospitalization) and discharge criteria are also important to talk about
    
    

Psychiatry

As with many of other specialties listed, psychiatry has both inpatient and outpatient components to its practice. For the sake of this post, we will focus on psychiatry’s inpatient component.

Subjective

• Identification/Chief Complaint (ID/CC)
  • “One-liner” that succinctly covers the patient’s name, highly relevant subjective patient data, and natures of their chief complaint
• Overnight Events
  • Notable events to report are ones that would be important for the team to know and would impact the care of that patient for the day (you have to use your judgement on this one!). 
  • If you’re admitting a patient (from the ED, from another unit, etc.), skip this.
• History
  • Interval history for the day for hospitalized patients
  • History of present illness for new admits
• Past Medical History (new admits only)
  • Present the active medical problems that are pertinent to evaluation and ongoing management
• Family Medical History (new admits only)
  • Gather and present the family medical history that you determine to be relevant to the patient’s care
• Past Surgical History (new admits only)
  • Present the patient’s prior surgical procedures that are pertinent to evaluation and ongoing management
• Medications and Allergies (new admits only)
  • Include doses for each medication the patient takes at home and how often they take them (also, be sure to ask how often they miss doses!!!)
    • Distinguish between in-patient medications and home medications
  • For allergies, ask what kind of allergic reaction they have to the med/food
• Health-Related Behaviors (new admits only)
  • Report additional health-related behaviors (substance use, alcohol use, etc.) that have not already been mentioned in the HPI
• Social History (new admits only)
  • Summarize the patient’s living situation, support systems, occupation, identity, and any social issues that could impact their care
• Review of Systems
  • Only present the pertinent positives for the OCP

Objective

• Vitals
  • Also include patient’s weight (kg) if newly admitted
• Ins and Outs (I/Os)
  • Report total fluids in, out, and the net amount, all within the past 24 hours (mL)
• Physical exam
  • This will mainly be the mental status examination (MSE), which objectively reports on the patient’s cognitive, emotional, and physical status at the moment of examination.

• Labs
  • Report the values of all abnormal lab findings
• Imaging
  • Report any new imaging results, stating what imaging study was done (e.g., CXR, CT AP, MRI of the L ankle, etc.) and the findings/impression of the films
• Other Diagnostics
  • This includes tests such as microbiology tests (e.g., respiratory viral panel) and pathology (e.g., biopsy)

Assessment

• Summary Statement
  • Re-state ID/CC from the beginning of the presentation
  • “... found to have ____”
  • “... concerning for ___”
• Problem List
  • Your differential diagnosis with your arguments for/against each diagnosis listed using patient’s history, physical exam findings, and other available data
• NOTE: If this is instead a return or check-in visit for an otherwise stable condition, then you would instead give your interpretation of the patient’s progress

Plan

• Your proposed plan for each problem listed above
• Usually problem-based
  • Be sure to talk about any medications to start/resume/stop (with method of administration), labs/imaging/other diagnostics to order, consults to call, etc.
• Disposition (aka the destination the patient will be discharged to after their hospitalization) is extra important to focus on in psychiatry, as many psychiatric patients have concurrent social struggles that may prevent access to stable food and housing. There is a good chance that you will be working closely with a social worker for many of your psychiatric patients.

Neurology

Neurology has both inpatient and outpatient components; however, this specialty generally focuses more on outpatient care. Therefore, the following OCP will be tailored to the outpatient setting.

 Subjective

• Identification/Chief Complaint (ID/CC)
  •  “One-liner” that succinctly covers the patient’s name, highly relevant subjective patient data, and natures of their chief complaint
• History
  • Quick history of what’s going on (the story)
    • Additionally, are they following up on a problem that they’ve been seen for? Or is it a new problem?
    • Emphasize pertinent positives and negatives
  • Other important details to know about the patient 
    • E.g., if they’re here for occasional lightheadedness, and you see they’re on a medication that is known to cause that, then be sure to mention it! 
    • Other important details that you may need to collect include things like sexual history, vaccination status, family medical history, etc.

Objective

• Vitals
• Physical exam
  • Focus will be on the neurological examination

• • • Mental status
    • Cranial nerves
    • Motor
    • Reflexes
    • Sensation
    • Coordination
    • Gait
  • Also include other organ systems relevant to the visit. The HEENT (head, eyes, ears, nose, throat) exam often accompanies the neurological exam
• Recent and Relevant Lab/Test Results
  • Imaging
  • ECG
  • etc.

Assessment

• Summary Statement
  • Re-state ID/CC from beginning of the presentation
  • “... found to have ____”
  • “... concerning for ___”
• Problem List
  • • Your differential diagnosis with your arguments for and against each diagnosis listed using patient’s history, physical exam findings, and other available data
  • When appropriate, explain where you think the patient’s lesion is localized to—brain, brain stem, spinal cord, motor neuron, peripheral nerve, NMJ, muscle—and use your history and physical exam findings to support your reasoning!
• NOTE: If this is instead a return or check-in visit for an otherwise stable condition, then you would instead give your interpretation of the patient’s progress

Plan

• Usually problem-based
  • Be sure to talk about any medications to start/resume/stop (with method of administration), labs/imaging/other diagnostics to order, lifestyle interventions (e.g., continue to monitor salt intake), etc.
  • Also, recommend when the patient should follow up in the clinic, if necessary

Pediatrics

Pediatrics has both inpatient and outpatient components that will dictate the details of the OCP. For guidance on the outpatient pediatric OCP, you can refer to the family medicine OCP section, as the details will be similar (minus some necessary pediatric-themed details to ask about and gather, which you will adjust throughout the rotation). The OCP below will focus on the inpatient pediatric OCP.

 Additionally, pediatrics is special in that rounding is often done via “family-centered rounds”, where the rounding team presents with the patient and their family in the room, allowing them to participate in the discussion of the patient’s care. This should not change the structure of your OCP, but it will certainly dictate your word choice and how you communicate complex medical topics in an attempt to foster understanding from the patient’s family. It takes some getting used to!

Subjective

• Identification/Chief Complaint (ID/CC)
  • “One-liner” that succinctly covers the patient’s name, highly relevant subjective patient data, and natures of their chief complaint
• Overnight Events
  • Notable events to report are ones that would be important for the team to know and would impact the care of that patient for the day (you have to use your judgement on this one!). 
  • If you’re admitting a patient (from the ED, from another unit, etc.), skip this.
• History
  • Interval history for the day for hospitalized patients
  • History of present illness for new admits
  • More specific to pediatrics: What questions or concerns do the parents have? What did they notice overnight? 
    • Vaccination status is also very important to note
• Past Medical History (new admits only)
  • Present the active medical problems that are pertinent to evaluation and ongoing management
• Family Medical History (new admits only)
  • Gather and present the family medical history that you determine to be relevant to the patient’s care
• Past Surgical History (new admits only)
  • Present the patient’s prior surgical procedures that are pertinent to evaluation and ongoing management
• Medications and Allergies (new admits only)
  • Include doses for each medication the patient takes at home and how often they take them (also, be sure to ask how often they miss doses!!!)
    • Distinguish between in-patient medications and home medications
  • For allergies, ask what kind of allergic reaction they have to the med/food
• Health-Related Behaviors (new admits only)
  • Report additional health-related behaviors (substance use, alcohol use, etc.) that have not already been mentioned in the HPI, if age-appropriate to consider
• Social History (new admits only)
  • Summarize the patient’s living situation, support systems, occupation, identity, and any social issues that could impact their care
  • Also include the parents’ health behaviors in the home, if known (to track things such as second-hand tobacco exposure, for example)
• Review of Systems
  • Only present the pertinent positives for the OCP

Objective

• Vitals
  • Also include patient’s weight (kg) if newly admitted
• Ins and Outs (I/Os)
  • Report total fluids in, out, and the net amount, all within the past 24 hours
    • I/Os are especially important in children. When kids get sick they tend not to eat, drink, or urinate.
    • Present I’s in mL/kg or, if they are taking PO, as a percentage of how much they should be drinking ([PO in mL]/[maintenance fluid calculation in mL/hr] x 24 hrs). 
    • For urine output, always present in mg/kg/hr. 
    • Also very important is how much oxygen they’re currently on and how that has changed in the past 12-24 hours. 
• Physical Exam
  • Present physical examination findings that are pertinent to the patient’s hospitalization
  • Always report abnormal findings regardless of organ system
• Labs
  • Report the values of all abnormal lab findings
• Imaging
  • Report any new imaging results, stating what imaging study was done (e.g., CXR, CT AP, MRI of the L ankle, etc.) and the findings/impression of the films
• Other Diagnostics
  • This includes tests such as microbiology tests (e.g., respiratory viral panel) and pathology (e.g., biopsy)

Assessment

• Summary Statement
  • Re-state ID/CC from beginning of the presentation
  • “... found to have ____”
  • “... concerning for ___”
• Problem List
  • Your differential diagnosis with your arguments for and against each diagnosis listed using patient’s history, physical exam findings, and other available data
• NOTE: If this is instead a return or check-in visit for an otherwise stable condition, then you would instead give your interpretation of the patient’s progress

Plan

• • Your proposed plan for each problem listed above
  • Usually problem-based
    • Be sure to talk about any medications to start/resume/stop (with method of administration), labs/imaging/other diagnostics to order, consults to call, etc.
    • Disposition (aka the destination the patient will be discharged to after their hospitalization) and discharge criteria are also important to talk about

Family Medicine

The practice of family medicine is largely centered around the outpatient, clinic setting (although they can and do practice in various inpatient settings as well). Therefore, this OCP structure will focus on outpatient family medicine. For inpatient family medicine presentations, please refer to the OCP for internal medicine, as they will be very similar if not the same.

Subjective

• Identification/Chief Complaint (ID/CC)
  •  “One-liner” that succinctly covers the patient’s name, highly relevant subjective patient data, and natures of their chief complaint
• History
  • Quick history of what’s going on (the story) 
    • Additionally, are they following up on a problem that they’ve already been seen for? Or is it a new problem?
  • Other important details to know about the patient 
    • E.g., if they’re here for occasional lightheadedness, and you see they’re on a medication that is known to cause that, then be sure to mention it! 
    • Other important details that you may need to collect include things like sexual history, vaccination status, family medical history, etc.

Objective

• Vitals
• Physical Exam
  • This will be for the system(s) relevant to the patient’s chief complaint
  • In addition, it’s also wise to examine the following systems, even if they’re not as relevant to the patient’s reason for seeing you:
    • Cardiac
    • Respiratory
    • Abdominal
    • Some aspects of the neurological exam (e.g., Mental status)
• Recent and Relevant Lab/Test Results
  • Imaging
  • ECG
  • PFTs
  • etc.

Assessment

• Summary Statement
  • Re-state ID/CC from beginning of the presentation
  • “... found to have ____”
  • “... concerning for ___”
• Problem List
  • Your differential diagnosis with your arguments for and against each diagnosis listed using patient’s history, physical exam findings, and other available data
• NOTE: If this is instead a return or check-in visit for an otherwise stable condition, then you would instead give your interpretation of the patient’s progress

Plan

• Usually problem-based
  • Be sure to talk about any medications to start/resume/stop (with method of administration), labs/imaging/other diagnostics to order, lifestyle interventions (e.g., continue to monitor salt intake), health guidelines to be aware of (e.g., due for HIV testing), and procedures to perform (e.g., ingrown toenail removal)
  • Also, recommend when the patient should follow up in the clinic, if necessary

Conclusion

The OCP is an invaluable skill that will allow you to communicate your understanding of your patient’s case to the rest of the medical team. Therefore, it’s essential that you have some sort of framework or structure to keep yourself organized. Feel free to revisit this post, adapt the details as you see fit for the rotation you’re currently on, and find what works for you.

See you on the wards!