Presenting a patient: oral and written clinical reports

• Presenting a patient is a clinical skill in its own right: you take a whole person, a whole record and a whole plan, and make them fit into a short, clear, useful message. ^[5]
• The spoken presentation is built in a fixed order: a one-line summary, the presenting complaint, the relevant history, the examination, the investigations, the assessment, and the plan.
• The ward round, handover and emergency call formats exist to make that message short and safe; Situation, Background, Assessment, Recommendation (SBAR) and its variants are the commonest.
• The same thinking is written down twice: the full admission note (history, examination, investigations, assessment, plan) at the start, and short SOAP progress notes afterwards.
• Good notes are dated, timed, signed, legible, honest about what was not examined, and use no dangerous abbreviations.

By the end of this page you should be able to:

1. Open a patient encounter, explain what you are about to do and obtain consent.
2. Perform and record a complete oral case presentation in the standard order, then shorten it to about one minute.
3. Hand over or refer using Situation, Background, Assessment, Recommendation (SBAR) or its inclusive variant ISBAR.
4. Write an admission history and physical examination note (clerking) and a SOAP progress note.
5. Avoid the abbreviations, units and dose designations that are commonly misread.
6. State the Royal College of Physicians (RCP), Royal College of Surgeons (RCS) and General Medical Council (GMC) expectations for medical records.
7. Turn a raw list of findings into a presentation and recognise the phrases that make one clear or unclear.

This page is about the skill of reporting a patient, not about any single disease. Every day you will assess patients, then tell other professionals about them: in a rushed ward round, in a clinic handover, in a referral call, and in the record that outlasts all of you. The product you are making each time is the same, a short, accurate, honest account of who the patient is, what is wrong, what you found, what you think, and what you are going to do. The formats differ because the settings differ.

The setting decides which format you use. A first presentation in front of a consultant rewards thoroughness, in a limited time. A ward round note from the next day should be new information and the active plan. A handover to the night team should be short, urgent and action-oriented. A referral to another specialty should frame the question and the question only. A discharge summary should be understandable to a patient, a general practitioner and a carer. An assessment is only as good as the account of it.

Presentation is also a safety skill. Misunderstood information between clinicians is a known route to harm. One review of structured handover reports that communication failures contribute to a substantial minority of malpractice cases. ^[2] Giving information in a predictable order, with the important finding first and the plan at the end, makes it far more likely that the next person hears it and acts on it.

This topic covers the preparation before the presentation, the order of presenting at the bedside and in conference, the normal and abnormal features of a presentation, how to speak and how to write, worked examples, common mistakes and self-checks. It is deliberately practical; there is no examination technique here that cannot be practised aloud with a colleague.

Preparation is done once and done early, before the patient is questioned or examined. A good presentation cannot be rescued by style if its facts are wrong, and facts are gathered only when the patient is respected and settled. The same steps apply whether you are clerking a new admission or re-presenting on a round, scaled to the urgency of the situation.

• Introduction. State your name and role and ask the patient's name and preferred form of address. Say briefly why you are there and how long it should take. Knock, ask permission and use a curtain or a side room where possible. This is both courtesy and consent.
• Consent. For a routine history and examination, consent is usually implied when the patient agrees to talk and cooperates. For anything sensitive, intimate, painful or potentially risky, obtain explicit consent, including the right to stop or to be accompanied at any stage. Consent to be examined is not consent to be presented at the bedside without privacy.
• Chaperone. Offer a trained chaperone for any intimate examination and for examinations in which you could be falsely accused or in which the patient is vulnerable. Record the offer and the response. A chaperone protects both parties and is part of standard practice.
• Hand hygiene. Clean your hands before and after patient contact, before any clean or aseptic procedure, and after exposure to body fluids, in accordance with current World Health Organization guidance on hand hygiene in health care. ^[4] If you are presenting at the bedside, clean your hands on approaching the patient and again when you leave. Keep equipment clean and do not reuse disposable gloves, swabs or instruments between patients.
• Exposure and position. Expose only what you need to examine, drape for dignity, and return the blanket or gown afterwards. Seat or stand the reporter so that you can see the patient and the hearers, and the patient can hear you. Place a chair, and do not talk across a supine patient as if they were absent.
• Materials. Have the notes, results, drug chart and observations to hand before you begin, so that you do not break the presentation to search. If a vital sign changes while you wait, re-check it before speaking. Set short expected times at the start if a senior is waiting: "This is a five-minute presentation of a 68-year-old man with abdominal pain."

The order below is the order used in teaching and in most hospital settings for a first, complete oral presentation of a newly seen patient. Learn it until it is automatic; you can then shorten or regroup without losing anything.

1. Announce the patient. Give the name, age and sex, the setting ("new admission to the medical take", "seen on the post-take round"), and the reason the patient is there. This is not a formality; the hearer cannot interpret the rest without it.
2. One-line summary (the headline). State the patient, the key problem, and its severity or stage, in one sentence. Example structure: "This is a 72-year-old woman admitted with breathlessness at rest and a new oxygen requirement, most likely decompensated right heart failure." If you cannot write the headline, you have not yet understood the case.
3. Presenting complaint. State the main symptom as the patient gives it, with its duration: "She has three days of worsening breathlessness." Do not merge it with your diagnosis yet.
4. History of the present illness. Tell the story in the order it happened, not in the order you took it. Include onset, course, severity, character where it helps (pressure versus stabbing), aggravating and relieving factors, associated symptoms, and the red flags. Quantify: numbers of episodes, doses, days, weights, distances. State specifically what is denied when it matters.
5. Relevant past, drug, family and social history. Filter for impact. A childhood fracture is irrelevant unless it left a functional deficit; a recent fall is essential. List drugs with doses where drugs cause or treat the problem. State allergies. State function (mobility, living alone, independence) because it changes the plan.
6. Examination. Give the general state first (well, distressed, jaundiced, cachectic), then the vital signs with the numbers and their trend, then the relevant systems in the same order every time. State what you did not examine or could not assess, because absence of evidence is not evidence of absence.
7. Investigations. Give only the results that change the plan, each with its value and its unit, and the date. Say "pending" or "not yet available" plainly. Do not recite a full blood panel unless asked.
8. Assessment, or problem list. Say what you think is most likely, and why. Say what could kill the patient soon. Separate active problems (pain, delirium, hypoxia) from background conditions.
9. Plan. Split it into immediate actions (next hour), diagnostic actions (what you are arranging), therapeutic actions (treatments started and their doses), and disposition (stay, escalate, transfer, discharge). Name owners and times for each. End with what you yourself will do now.

For a quick handover or a short ward round, aim for about one minute. Use this shape:

• Sentence 1: patient, setting, and headline.
• A sentence for the symptom and its timeline.
• A sentence for the key abnormal findings and vital signs.
• A sentence for the most likely diagnosis and the dangerous alternative.
• A sentence for what is being done and what you need now.

Do not read a full history in a one-minute presentation. If the senior wants detail, they will ask, and then you give the section they asked for. The ability to compress is the skill; completeness is the starting point, not the product.

A ward round presentation is shorter than a clerking presentation because the patient is already known. The usual shape is a one- or two-sentence overnight-event update, the current problem, the relevant new findings or tests, the assessment, and the plan for the day. Senior-led rounds often use the problem-oriented form: for each active problem give the data, the assessment and the plan. ^[1]

Handover is about transfer of responsibility, not about teaching the case. Use a fixed framework every time:

• SBAR (Situation, Background, Assessment, Recommendation). Standing for Situation (a concise statement of the problem), Background (pertinent and brief information related to the situation), Assessment (analysis and considerations of options, what you found and what you think), and Recommendation (action requested or recommended, what you want). ^[2] It was developed as a means of framing any conversation that requires a clinician's immediate attention and action. ^[2]
• ISBAR (or ISoBAR). An inclusive variant that adds Identity and, in some versions, an explicit Observation line before Assessment: Identify (yourself and the patient), Situation, Background, Assessment, Recommendation. It is widely used to reduce identity confusion during transfers.
• Ward round summary. For a stable patient, a one-line update plus "plan today" is enough: overnight observations, pain score, new results, the key physical changes, the plan. Do not re-present the whole case.

Choose the framework by urgency, not by preference. Use SBAR for a deteriorating patient, a referral or an out-of-hours call. Use the ward-round summary for a stable patient at a planned round. Use the full clerking presentation for a patient the team has not met.

When a patient is getting worse, present the change, not the case. State when they were last seen and well, the current observations and their trend, the abnormal physical findings, the treatment given so far and the response, the latest results, and what you think is most likely plus the dangerous alternatives. Then state, plainly, what you are asking for and by when. If you are unsure, say you are unsure and ask for help at the start, not at the end.

In this skill the findings are features of the presentation or record rather than signs of disease: the components that must be present for it to be safe. The Table lists the ones most commonly omitted. The heading "Normal and abnormal" here means "present and correct versus missing or misleading."

The exact way to speak is as follows. The words are a teaching style; use your own, but keep the order.

1. Lead with the most important finding. The first complete sentence should tell the hearer why the patient matters today. Not "This is a 67-year-old man who has been on the ward for six days" but "This is a 67-year-old man whose oxygen requirement has doubled overnight." Everything else is context.
2. State the summary, then the detail. Say the headline, then the detail that supports it, not the other way around. Hearers forget the middle; make sure the beginning is right.
3. Group the normals. Say "Cardiovascular examination normal" or "Vital signs stable, temperature normal" once, instead of listing every normal component. Spend time on the abnormal.
4. State the negatives that matter. If chest pain is the question, say "no pleuritic pain, no haemoptysis, no risk factors". A negative that rules in or out a dangerous diagnosis must be spoken, not assumed.
5. Quantify. Say "88 per minute" not "fast"; "94% on four litres" not "on oxygen"; "three days" not "a short while". Counts, doses and distances carry the clinical weight.
6. Use plain language for the patient and precise language for the team. Say "heart attack" to the patient and "ST-elevation myocardial infarction" to your senior. In a bedside presentation with the patient listening, avoid frightening language that the patient has not heard said gently first.
7. End with the summary and the differential. One sentence for what you think: "I think this is community-acquired pneumonia." Then the plausible alternatives in order of likelihood and danger: "but pulmonary embolism and heart failure are realistic possibilities."
8. Close with the plan. Even if you are not expected to propose one, closing with "So I would like to ask about..." is appropriate. In a senior-led round, give the plan as yours unless corrected.

The matching written entry uses the same order and is shorter. Write the headline and the abnormal findings; record the normal in grouped shorthand. Only abbreviations you have explained are allowed, and they must be universally understood in your setting. Write normal grouped systems as a single phrase, and give a question and a plan at the end.

The admission note (often called clerking) is the permanent record of the first assessment. Formal guidance for generic medical record keeping standards has been produced by both the Royal College of Surgeons and the Royal College of Physicians, setting out essential information for admission documents. ^[6] Since 2007 the Royal College of Physicians has advised that data recorded or communicated on admission, handover and discharge should be recorded using a standardised proforma. ^[6]

A complete admission note contains, in order:

1. Patient identifying details, date and time of the note, and your name, grade and contact or GMC number where required.
2. Presenting complaint.
3. History of the present illness, with dates and quantities.
4. Background, drugs, allergies and sensitivities, vaccines where relevant.
5. Family and social history, including functional status and living situation.
6. System review of the remaining systems, negative as relevant.
7. Examination findings, system by system, including vital signs and scores used.
8. Impression or assessment and working diagnosis.
9. Differential diagnosis.
10. Problem list.
11. Plan, with investigations, treatments and disposition.
12. Consent, capacity and chaperone where relevant.
13. Who has been informed and who is responsible.

The General Medical Council and the Royal College of Surgeons recommend that every clinical entry include the date, the time, the author's full name, the author's signature and an identification number such as a GMC number, to maintain accuracy. ^[7] In audit these are the parameters that are most often missing from ward round notes. ^[7]

Progress notes are short: they record change, the active problems and the plan. The SOAP form is the common original structure and remains the standard in many records:

• S (Subjective): what the patient reports since the last note, including pain, new symptoms, sleep, appetite, mood and tolerance of treatment. Use the patient's own words where helpful.
• O (Objective): new observations, physical findings and results since the last note, including only new or changed information.
• A (Assessment): your clinical judgement of where things now stand, and any change in the diagnosis.
• P (Plan): the actions, who will do them and when, with a review time.

Avoid copying the whole admission note into each progress note. SOAP notes are written or typed as part of the medical record, and they are educational as well as clinical; a systematic review of educational interventions in this area emphasises that documentation is integral to safe practice and that students need repeated practice to reach a working standard. ^[7] Write one note per significant event or per day, dated and timed.

Oral case presentations on rounds have traditionally used the same SOAP order since the 1960s, and one comparative study found that trainees preferred an alternative events-plus-assessment-and-plan format for already-known inpatients in 8 of the 10 domains assessed, including advancing care and time efficiency. ^[1] Both formats should be recognised; use whichever your team uses.

Abbreviations are useful only when everyone in the clinical team understands them exactly. A systematic list of error-prone abbreviations, symbols and dose designations has been compiled from reporting programmes, and those that appear on The Joint Commission "Do Not Use" list (Information Management standard IM.02.02.01) must be included on any organisation's own "Do Not Use" list. ^[3] Common examples that are misread include single-letter and easily confused units and dose designations such as "U" for units (looks like zero) and "IU" (looks like I.V.), "QD" and "QOD" (mistaken for each other), "MS" (morphine sulphate or magnesium sulphate), and "MSO4" and "MgSO4" (confused with each other). ^[3] Trailing zeros after a decimal point and naked decimal points without a leading zero are also widely cited as dangerous.

In addition, keep local usage visible. Define any abbreviation that is not universal in your setting on first use, for example "APTT (activated partial thromboplastin time)" or "HF (heart failure)", and avoid abbreviations in notes that will be read by patients or general practitioners unless they are universally understood. Never invent abbreviations; if you are not certain a reader will understand one, write it in full.

Numbers should also be written safely: put units with every dose and every lab result, and write dates and times in the local unambiguous format.

An honest record is often the hardest part. Record what was not done and why: "Rectal examination not performed: patient declined" or "Neurological examination limited by dysphasia: motor and sensation across all four limbs not formally tested." Document also what was attempted but unobtainable: "Pulse irregular, rate counted from the apex or ECG only; peripheral count unreliable."

Do not use "NAD" (no abnormality detected) to mean you did not examine. If a system was not examined, write "not examined" or "not relevant" and be ready to explain why. Where a finding is uncertain, write "uncertain", "equivocal" or "clinical judgement" and, if it matters, arrange a re-examination or a second opinion. If a parameter was not recorded, say so rather than writing "normal", for example "Respiratory rate not recorded."

All examples below are illustrative and use invented patient details. They are not transcripts of real patients.

Illustrative normal (invented patient). Spoken: "This is Mrs Davis, aged 42, seen as a new medical admission for fatigue over six weeks. She has no breathlessness, chest pain, fevers or weight loss, and her sleep and mood are normal. On examination she is well, afebrile, with normal pulse, blood pressure and oxygen saturation, and the cardiovascular, respiratory, abdominal and neurological examinations are normal; urine testing is negative. The blood count, renal and liver tests and thyroid function, checked today, are normal. I think this is uncomplicated tiredness with a normal assessment, but I will complete a fatigue history and recheck; I would like to exclude iron deficiency and depression."

Illustrative abnormal one (invented patient). Spoken: "This is Mr Patel, aged 68, who was well until this morning, now breathless at rest with a new oxygen requirement. He has had four days of cough and sputum, no chest pain, no haemoptysis and no leg swelling. He has chronic bronchitis and hypertension. On examination he is distressed, temperature 38.2, pulse 104, respiratory rate 28, oxygen saturation 88 percent on room air and 94 percent on four litres; there are crackles at the right base and no wheeze; chest percussion is dull at the right base. White cell count is 14.2 and the chest X-ray shows right lower-lobe consolidation. I think this is community-acquired pneumonia; heart failure and pulmonary embolism are important alternatives. He needs antibiotics, fluids and oxygen titrated, and a NEWS2 and senior review."

Illustrative abnormal two (invented patient). Spoken: "This is Mr Okafor, aged 55, admitted with diarrhoea and vomiting for two days, now light-headed on standing. He has no fever now but had one yesterday, and has drunk little. He has type 2 diabetes and takes metformin and ramipril. On examination he is dry, pulse 112 and regular, blood pressure 95 over 60 sitting and 78 over 50 standing, temperature 37.2, respiratory rate 20, oxygen saturation 97 percent on air; abdomen soft and non-tender; the rest of the examination is normal. Urea is 12.4, creatinine 145, sodium 128 and potassium 3.2, and a blood gas shows metabolic acidosis. I think this is hypovolaemic acute kidney injury on top of his usual medicines; diabetic ketoacidosis and sepsis are the dangerous alternatives. He needs an intravenous fluid bolus, stopping the ramipril, a catheter and close review."

Illustrative abnormal three (invented patient). Written progress note (SOAP): "S: reports less breathless today, settled night, took all medicines. O: respiratory rate 20, oxygen saturation 95 percent on two litres, temperature 37.0, pulse 84; right-sided crackles reduced; repeat urea 8.2, creatinine 118, white cells 10.1. A: responding to treatment, renal function improving; still needs oxygen, so discharge not yet. P: continue antibiotics, step down to oral when afebrile 24 hours, repeat blood count and renal profile tomorrow; plan discharge the day after tomorrow if stable."

• Presenting chronologically rather than by importance. The hearer must wait three minutes for the punchline. Put the diagnosis and the plan in the first minute and the details afterwards.
• Reading everything. Observations, drug doses and lab values that do not change the plan make the presentation unreadable. Filter.
• Using unexplained abbreviations. "She has CKD 4, HFrEF, AF and a TIA last year" is efficient only if everyone shares the decoding. Define on first use or write in full.
• Omitting negatives. Leaving out that chest pain is absent, or that the neurological examination is normal, makes the hearer assume you did not think of it.
• Writing a positive finding you did not establish. "Chest clear", "abdomen soft, non-tender" and "calm affect" are claims. If you did not examine or are unsure, say so.
• Copying the whole admission note into daily notes. Progress notes should record change, problems and plan. The record quickly becomes unreadable.
• Leaving tasks without owners or times. "Monitor renal function" and "check bloods" are not plans. Write who and when.
• Being falsely certain. Saying "this is clearly a viral illness" before ruling out sepsis is both poor content and a safety problem.
• Using ambiguous units. "Sugar 9" or "BP low" is not information. Write the value and the unit.
• Failing to state what you could not assess. If a patient cannot speak, or is in pain, or has had recent sedation, say what was limited and arrange the follow-up.
• Talking across the patient. A bedside report is a public event. Tell the patient first, then present, and never leave them without an explanation.

• Presentation is a single skill that recurs in many formats: clerking, ward round, handover, referral, discharge summary.
• Prepare the patient, yourself and the information before you start.
• The classic spoken order is one-line summary, presenting complaint, history, examination, investigations, assessment, plan.
• The one-minute version is five sentences: patient and headline, timeline, findings, diagnosis and alternatives, action.
• Use SBAR or ISBAR for handover and urgent calls; keep the ward-round summary short.
• The admission note records the first full assessment; RCP and RCS have produced generic medical record keeping standards and RCP has advised since 2007 that admission, handover and discharge data should be recorded on a standardised proforma. ^[6]
• Each entry should carry date, time, full name, signature and an identification number, per GMC and RCS guidance.
• SOAP progress notes record subjective, objective, assessment and plan, and should show change rather than repeat the original.
• Record negatives and unexamined systems honestly; a false normal is worse than a gap.
• Avoid ambiguous abbreviations, dangerous units and dose designations; use your institution's "Do Not Use" list.
• Clean hands and standard precautions apply before and after patient contact, as recommended by current WHO guidance.
• Every note should be testable against a simple question: does the next clinician know who, what, where, when, why and what next.

Plain-text related topics include: communication and information sharing, neurological examination, cardiac physical examination, respiratory examination, abdomen examination, history taking, clinical handover in emergency departments, referral letters, discharge summaries, capacity and consent, confidentiality and record keeping, prescribing and medication safety, infection prevention and hand hygiene, deteriorating patient and early warning scores, patient safety incident reporting, and undergraduate OSCE and clinical skills training. These MedGrasp topic links are listed as plain text until the corresponding pages are verified.