GUIDELINES AND FORMAT
ON
CASE MANAGEMENT PRESENTATION-DISCUSSION AND SHARING OF INFORMATION
Format
Case Management Presentation-Discussion and Sharing of Information
on
Chief Complaint
(Name and Title of Contributor)
Present Database
General Data
Minimum: Initials of patient, age, sex
As needed: Occupation, residence, religion
Chief Complaint
History of Present Illness/Condition
As needed:
Past Medical History
Personal Social History
Obstetrical and Gynecological History
Physical Examination (Use illustrations as much as possible.)
*Include core data on chief complaint and significant symptoms and signs:
Onset (date/time noticed)
Characteristics of chief complaint and significant symptoms and signs (eg - tumor – size,
consistency, nature (solid/cystic), mobility, border, tender or not, etc)
Associated symptoms and signs
Previous medical consult findings
Must include the following 4 parts:
I. Clinical Diagnosis
II. Paraclinical Diagnostic Procedures
III. Treatment
IV. Prevention and Health Promotion
I. Clinical Diagnosis
1. Identify data from database which can serve as cues for a clinical diagnosis.
Age/Sex
Symptoms
Signs
2. Based on pattern recognition and prevalence, decide on the primary and
secondary diagnoses. Primary diagnosis is what you think is the most likely
diagnosis and secondary diagnosis is the closest second.
Primary Clinical Diagnosis:
Secondary Clinical Diagnosis:
3. Illustrate/explain how you arrive to the primary and secondary clinical diagnoses.
Use the clinical diagnostic processes of pattern recognition and prevalence.
Use algorithm as much as possible.
Use pathophysiology to support your primary and secondary clinical diagnoses.
II. Paraclinical Diagnostic Procedures
1. Restate your primary and secondary clinical diagnosis.
2. Decide on whether you need a paraclinical diagnostic procedure or not.
If YES, why? If NO, why?
Use the processes of certainty and proposed treatment of your
primary and secondary diagnoses as basis.
*Place figures such as 10%, 50%, 70% certain and basis of certainty, whether based on
signs, symptoms, and prevalence or just on symptoms and prevalence or just
prevalence. Use 90% as a cut-off for “certain” and “quite certain.” Below 90%, “not certain.”
**If you decide you don’t need a paraclinical diagnostic procedure, proceed to
TREATMENT.
3. If you decide to go for a paraclinical diagnostic procedure, select one from at
least two procedures that may be done.
Use the following table:
4. After selecting one paraclinical diagnostic procedure, briefly describe how it is
done and what will be the result that will firm up your diagnosis.
5. Present the paraclinical diagnostic procedure(s) that were done on the patient starting with the
one that you are recommending. Then, interpret the results.
III. Treatment
1. State your pretreatment diagnosis - both primary and secondary.
2. State the goals of treatment for the primary diagnosis.
3. Decide on the treatment modality.
4. Decide how you evaluate the result or outcome of your proposed treatment.
5. If data are available, present the treatment procedures done on the patient and
their outcome.
IV. Prevention and Health Promotion
*Use illustrations as much as possible.
1. State your final diagnosis.
2. Briefly describe how you will advise patient on prevention of the disease and health promotion.
Use pathophysiology.
Advise on screening.
Advise on early detection.
V. References
Criteria to be used in evaluation
Clear
Adequate in terms of content
Management goals
Rapport
Clinical diagnostic process
Paraclinical diagnostic process
Treatment process
Indication for referral
Advice
Health promotion and maintenance
Format followed
Presence of references
Within the prescribed length
See Samples of CMPDSI for further guidance.
Use the Patient Management Framework as guide.
ROJ@12sept30