Patient information Chief complaint Personal history Family history Socioeconomic history Occupational history III. Admitting diagnosis, lab data, and x-ray. Course of admission:* Medications—all Lab data—including I & O, ABGs, and x-ray Therapy—respiratory therapy, physical therapy, occupational therapy, etc. Prognosis Course of admission data should be limited to the pertinent data. The patient’s progress will be covered in detail for the period of time that the student is working with the patient. Course of admission prior to student contact, if lengthy, must be covered in the presentation but not as detailed as time of student contact.** The topic that is to be discussed should be the reason for hospitalization of the patient. *Patients with preexisting disorders—example: CHF with history of asthma. The asthma may be included in course of admission section and its implications to patient care should only be mentioned. **Complications should be mentioned as so during prognosis section. Example: If patient develops a pneumothorax, this is briefly mentioned in prognosis section.
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