Patient Presentation

The purpose of the patient presentation is to give the attending physician or senior consultant a comprehensive overview of the patient's situation/findings in the shortest possible time and to formulate a proposed diagnosis and treatment plan.

A structured patient presentation makes the work easier for everyone involved and speeds up workflows in the clinic.

Presenting efficiently also simplifies the writing of a report.

Preparation

Before the presentation, history and findings are collected and summarized

History

Document in writing in the medical record

• Reason for referral
• Brief summary of the patient's history
  • Surgeries/trauma
• Secondary diagnoses (systemic diagnoses and therapy/medications)
• Current complaints
  • Pain/decreased vision

Findings

Document in writing in the medical record

• Current findings
  • visual field/RAPD/color vision if applicable
  • subjective visual acuity
  • IOP
  • anterior segment
  • posterior segment
    • OCT if applicable
• Epicritic assessment
• Proposal regarding therapy/management

Presentation to the supervisor

• X is referred by Y with the question of Z
• X has complained of Y for Z days
• Relevant secondary diagnoses
• Today's findings
• My diagnosis
• My proposal for therapy/management
• Meanwhile, the supervisor examines the patient and dictates their findings
• The presenting physician corrects or supplements their own findings
• Document responsibility for assessment/management
  • Presentation in consultation: "vidit-dixit" abbreviation
  • Presentation by phone: "dixit" abbreviation
• Internal referral: write a brief report as a task via Hexabit Luna to the referring physician
• External referral: create the "formal report" template on the day of examination and place it in the tray of the responsible attending/senior physician
  • Every referral receives a report
  • no report without the signature of a specialist physician

FAQs

When is presentation to an attending or senior physician necessary?

In principle, it is at the discretion of the resident or attending physician to examine patients, establish diagnoses, and define therapy and management. Medical responsibility lies with the treating physician.

If a physician is unsure, they can consult a more experienced physician.
Residents should have this option available at all times, if necessary by phone, i.e. a specialist in ophthalmology is always reachable on call.

• During emergency duty, outside the clinic's opening hours, the on-call physician of the nearest tertiary care center can be consulted
• For postoperative questions, the operating surgeon is the contact person

How is consultation handled for urgent questions?

For urgent questions during consultation hours, an attending physician present can be briefly interrupted during their own consultation or reached by phone via the front office of Augenzentrum ONO Wallisellen.

Less urgent questions can be submitted via the practice software Hexabit Luna as a question to an attending or senior physician.

Ask or not ask?

In principle, ONO follows the credo "there are no stupid questions, only stupid answers".
For the clinic's workflow, it is most efficient when trainees learn from their questions and progress is evident, i.e. the trainee should try to distill a system from the answers to their questions in order to develop a strategy for answering similar questions in the future. EyePedia contains a wide range of guidelines and can be used as an aid to memory.

Report or no report?

If a patient, referring physician, or health insurer requests a report on the current examination or for a referral, we should write it for them. It is most efficient to write the report right away while the patient is still in the consultation.
> more about reports