GUIDELINES AND FORMAT

ON

CASE MANAGEMENT PRESENTATION-DISCUSSION AND SHARING OF INFORMATION

See MS File if there is distortion of contents in this site.

cmpdsi_guidelines_format_rj_12jun30

Format

Case Management Presentation-Discussion and Sharing of Information

on

Chief Complaint

(Name and Title of Contributor)

Case Presentation

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

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Case Management Discussion

Must include the following 4 parts:

I. Clinical Diagnosis

II. Paraclinical Diagnostic Procedures

III. Treatment

IV. Prevention and Health Promotion

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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.

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.

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Sharing of Information

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References

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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

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See Samples of CMPDSI for further guidance.

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Use the Patient Management Framework as guide.

ROJ@12sept30