Presenting a Patient or Client to the Medical Team

By: Judith P. Bradley, CSW

Aside from clinical training and experience, the one skill a clinician must develop is that of communication. That sounds simple enough—talking and hearing. These abilities are not enough. Let’s look at the ability to LISTEN with purpose and SPEAK with intent. These skills will serve you and the recipient of your services well. The cornerstone of human service is the exchange of information, whether hard data or the interchange of clinical thought. I will address one area of the clinical process, and that is the presentation of a client to colleagues.

Your information must be relevant and presented in an organized and succinct manner. You must have a template, either in an agency approved written format or your own “cheat sheet.” In some cases, with years of experience, the format can be in your head. I do not recommend it. If you overlook pertinent information, it may get lost in the process. Train yourself from the beginning to be thorough. Over-confidence at any stage in your career can lead to a poor outcome. I recommend that you begin to study and learn your contact forms and use them wisely. Take your own ancillary notes if you must, but the information incorporated into your agency notes must be accurate and appropriate. This will be your guide for presentation.

The presentation itself can feel daunting. It does not have to be. Once you have your pertinent written data, you must then use the skill of speaking with intent. If you are “all over the place,” the clinical picture of your client will be lost in words. Over time, I learned to use the following format when speaking:

Objective assessment of client at initial presentation (what I see)
Client’s assessment of self and presenting problem (what I hear)
Pertinent bio/psycho/social data (information I collect)
Collateral information, if taken (from whom and in what context)
Clinical impression, if appropriate in agency (what I determine thus far)
Initial disposition of client, including colleagues consulted (what I did)

The content of the above likely does not include exact information you need to present, unless you are in the behavioral health setting. Nonetheless, there will be necessary data you must impart to serve your client. You may use the above as a guide to organize and train your own mind to consistent gathering of information.

Now let us look at presentations I have heard in real clinical settings. The clients are real but, of course, with no identifying information.

She came to the ER last night and uh said she had been feeling depressed and um her husband was with her and said she had been acting different for a while and um he asked her if she thought she needed help and she said yes so he um brought her to the ER. She looked depressed so I told her to make an appointment with the clinic.

He called and said he wanted help with his drinking problem and we had a detox bed and the physician said okay, let’s admit him, so we did.

At a shift change: What can I say about him, he is as crazy as ever. (Rolling of the eyes.) His meds were given and he went to bed and slept the whole shift.

While working inpatient in an adolescent mental health facility, I began realizing that all shift notes were “canned,” and at shift end, many reports were identical or similar. They went something like this: Patient participated in group activities. Worked well with peers. No complaints reported. This is an example of filling in the blanks in order to get a paycheck. Who was the loser in this game?

These are extreme but, unfortunately, common examples. I once read an emergency contact sheet written by a psychologist who was moonlighting at a community hospital. The demographics were incomplete, and the only other written information on the contact form was “depressed, will make a clinic appointment.” On the night shift at a mental health walk-in clinic, I sat in on a presentation at which the physician had to ask the clinician six times to go to the lobby and get basic history from the client. At what point were any of the above examples serving the client? None.

Please carefully read the following presentation.

Patient is a 54 y.o. married white female who presented to the Emergency Department at 11:05 p.m. complaining of being “too depressed to sleep” X2 weeks. She presents as unkempt, thin, tearful at times, withdrawn as evidenced by dropping of the head and little eye contact. She gives a complete history with some prompting. Her thought process and content are normal. Some psychomotor retardation is noted, as evidenced by slowing of verbal responses and motor movement. Her affect was congruent with mood described. She denied suicidal intent and homicidal ideation but states, “If I could sleep, I don’t care if I don’t wake up.” She reports the duration of the symptom X2 weeks as well as feeling tired X “about a year.” She denies any other psychiatric symptoms. The precipitant to this visit was, “I can’t go another night like this.”

She has been married to her current spouse X 30 years with two adult children. She reports no history of psychiatric treatment, no psychogenic medications. She does report a history of mom suffering from depression following menopause in her mid-fifties. Mom’s medical doctor treated her with tri-cyclic antidepressant meds, but she remained dysthymic until her death at age 79. She knows of no other familial psychiatric history. Patient is status/post colon resection due to diverticulitis X 8 months ago by Dr. N. with good results. She reports her symptoms have increased slightly since the surgery. Her primary physician is Dr. B., whom she has not consulted. The patient states that menses is slight and irregular X 2 years, and she has not seen a gynecologist X3 years. She is currently taking meds for increased cholesterol and denies any alcohol, drug, or tobacco use.

I conducted a collateral interview with patient’s husband, and he concurred with patient's presentation and only disagrees with the duration of the depressive symptoms. He reports that she has had trouble sleeping for 2-3 months, as well as intermittent tearfulness, and decreased activity and anhedonia X “a couple of years.” He presents as a responsible adult, loving and caring toward the patient, but frustrated that “he can’t do anything to help her.” She has refused to get prior treatment because “she doesn’t want to be like her mother.”

I consulted with ER staff physician Dr. L., who examined the patient and gave medical clearance. Dr. P., psychiatrist on-call, was contacted and agreed to admit the patient to the Behavioral Health Unit for observation and treatment. Any questions?

Now, let us dissect the above presentation. Do not be distracted by the clinical information, as your agency and your job responsibilities may require completely different data. Let us just look at the manner in which the information was presented, not the content. Keep in mind some buzzwords: succinct, organized, purposeful, and relevant.

Succinct describes a statement that is to the point with no superfluous verbiage. Let us take, for example “normal thought content.” That phrase rules out a litany of psychiatric symptoms. Keep your descriptive words to a minimum, unless they are pertinent. Never, never attach motive. I have heard many times the phrases, “She just needs to leave him,” or “He just needs to get a life.” Also, unless diagnosed properly, never assume a client’s underlying problem, such as, “I’ll bet she was abused,” or “Those kids need to be taken away,” or, “She is just staying with him for the money,” or the all-time favorite, “She’s just borderline” (meaning Borderline Personality Disorder).

We all know what organization means. How many of us really are organized? In a presentation setting, organization is crucial. The time to implement your organization plan is when you sit down with the client, not when you are faced with a presentation or written notes. Know what you are going after, keep the client on task, and forge ahead. It is natural for a client to start talking. You may be the only person who will listen. This will likely come in disjointed spurts of verbiage. That is understandable. If there were neither dysfunction nor serious need, you would not be having the conversation. Your organizational skills will bring the client back. You may need to use gentle nudging or skills that require more assertiveness. I have found the following phrases helpful:

Tell me more about your family history.
You were telling me a moment ago about _________. May we finish talking about that?
You know, Mrs. N., we are going to want to talk about that later, but right now I need to ask some questions so we can hurry and get you started.

Unanswered questions need to be documented as, “Client either unwilling or unable to answer the question,” or “Client is poor historian.” Never leave a blank. The fact that the question went unanswered could be clinically relevant. It could speak volumes.

Ask purposeful questions. You are the organizer. For instance, has the client been ill recently? If yes, then when, what, duration, treatment, family history, status. Do not allow the client to begin with a narration of the course of the illness, including how many stitches he or she had and whether or not the neighbors helped. Purposeful may sound sterile and clinical. Thus, you must have a trusting rapport with the client. If you speak in clear non-clinical terms, the client will feel comfortable. If you blast the client with big words and even bigger ego, the client is likely to neither trust nor utilize your agency. This is the worst outcome possible.

This takes us to relevancy. You are in control, you are the organizer, and you are responsible for the information, which will take this client into the next crucial phase of treatment. You are the gatekeeper. Generally, a client will continue to talk and emote. Listen intently and glean relevant information. The client cannot be allowed to talk indefinitely, as there are time constraints. Nor is it helpful for a client to complain without end. Remember boundaries. However, many times while answering questions or explaining dilemmas, you will glean pertinent data. So listen with purpose. Your purpose should be clear by now. You will be ushering this human being into a team of professionals who will, in no small part, help determine the outcome of his or her future.

In conclusion, the information you collect and subsequently pass off in the process is crucial. I cannot say that missed information will sabotage a client’s treatment, but it can certainly hold it up. It could take time for information to surface again. Thus, I reiterate: Listen with purpose and speak with intent. It is simply a matter of knowing what you need and gleaning it with respect, reporting it in an organized and succinct manner, while treating your client and colleagues professionally.

So, remember the following:

Organization starts before your contact with the client.

Gather your information in a non-sterile manner.
Be thorough and focused. Remember what information you need.
If the above is accomplished, you will be prepared for your presentation with the help of an organizational tool.
Your focus in presentation is to pass on relevant data in order for the process to continue seamlessly.
Use intent in speaking without irrelevant verbiage. You must stay focused and keep your colleagues on task. They will wander.
Be succinct and concise. If information is missing or sketchy, report the reason.
Always end with “Any questions?” or “Are there questions?”
Do not be intimidated. You are prepared. It becomes second nature with practice.
Graciously accept and learn from feedback. It is the professional way!

Judith P. Bradley, CSW, practiced for many years in the field of behavioral health and crisis intervention. She has retired to coastal North Carolina, where she will soon begin consulting.