The Improving Doctor

Acing the “Impression” of the Oral Presentation

The Impression, or as some call it, the “Assessment” section of a clinical note, is the brief summary statement, its like the 2-minute pitch to the venture capitalist to get $$$$ in funding. You’ve got to prove your case and be confident in your choices.

Every impression should have a similar ring to it. The story follows as such, patient intro, PQRST, pertinent positives, pertinent negatives, pertinent physical findings (& nil findings), pertinent labs (& nil labs), and lastly, the clinical reasoning… I suspect this is due to/related to X disease because of JKL reasons. I am also considering Y and Z, but no ABC to support these findings.

The last sentence  makes your clinical reasoning transparent to your listener, which will allow them to agree with you or improve upon your judgment. Your attending will begin to trust your decision-making, and when you aren’t correct (it happens), being corrected will make you a better doctor for your patients. Win-win.