. 2023 Jun 14;15(3):373–377. doi: 10.4300/JGME-D-22-00690.1

Table.

The Problem-Based Presentation Structure and Example

Structure	Example
Opening Sentence • Name • Age • Major medical problems • New or return • Last seen in clinic/last seen by you • Issues addressed today Problem 1 • Subjective No. 1 • Objective No. 1 • Assessment/plan No. 1 Problem 2 • Subjective No. 2 • Objective No. 2 • Assessment/plan No. 2 Problem 3 • Subjective No. 3 • Objective No. 3 • Assessment/plan No. 3 Health Maintenance (if addressed) (Even if busy, try to address 1 item each visit) • Vaccines • Age-appropriate screening • Habits Return to Clinic and Billing Level	Mr M is a 70-year-old man with a history of hypertension and COPD who presents today for follow-up. He was last seen by me 3 months ago for a regular visit. Today we discussed new wrist pain, hypertension, and health maintenance. Regarding his right wrist pain, he states onset was gradual and is worse with activity. Associated with numbness/tingling. OTC meds are not helping. Physical examination is notable for positive Tinel's and Phalen's sign. Likely carpal tunnel syndrome, plan to use splint and physical therapy, follow-up in 2 months. [pause for attending feedback] For his hypertension, he is taking his amlodipine 10 and lisinopril 20 as prescribed. BP today is 145/88, but he reports SBP is 120s at home. I provided him with a BP log and we will review it at his next appointment. [pause for attending feedback] For health maintenance, he is due for a screening colonoscopy. He also received his flu shot today. Other immunizations up to date. I want to see him back in 3 months and bill him a level 4.

Structure

Example

Opening Sentence • Name • Age • Major medical problems • New or return • Last seen in clinic/last seen by you • Issues addressed today Problem 1 • Subjective No. 1 • Objective No. 1 • Assessment/plan No. 1 Problem 2 • Subjective No. 2 • Objective No. 2 • Assessment/plan No. 2 Problem 3 • Subjective No. 3 • Objective No. 3 • Assessment/plan No. 3 Health Maintenance (if addressed) (Even if busy, try to address 1 item each visit) • Vaccines • Age-appropriate screening • Habits Return to Clinic and Billing Level

Mr M is a 70-year-old man with a history of hypertension and COPD who presents today for follow-up. He was last seen by me 3 months ago for a regular visit. Today we discussed new wrist pain, hypertension, and health maintenance. Regarding his right wrist pain, he states onset was gradual and is worse with activity. Associated with numbness/tingling. OTC meds are not helping. Physical examination is notable for positive Tinel's and Phalen's sign. Likely carpal tunnel syndrome, plan to use splint and physical therapy, follow-up in 2 months. [pause for attending feedback] For his hypertension, he is taking his amlodipine 10 and lisinopril 20 as prescribed. BP today is 145/88, but he reports SBP is 120s at home. I provided him with a BP log and we will review it at his next appointment. [pause for attending feedback] For health maintenance, he is due for a screening colonoscopy. He also received his flu shot today. Other immunizations up to date. I want to see him back in 3 months and bill him a level 4.

Abbreviations: COPD, Chronic obstructive pulmonary disease; OTC, over the counter; BP, blood pressure; SBP, systolic blood pressure.