How to Present a Patient to a Specialty Faculty:
Use the template below to make sure you have all the information to do a patient presentation, usually for a
particular problem. This is the same process you will use to write consults to your colleagues when you’re in practice.
The concept: You are making an introduction for your patient so they feel they have been smoothly handed off to someone
who understands their problem. Of course the specialist will do their own exam…of course the specialist will form their own
opinion, but this is an opportunity to give them as much pertinent background as you have already gleaned so they can look
informed to the patient and work efficiently. They will appreciate it…and remember it when they need to refer patients.
Specialists are responsible for the care they perform; they do not perform procedures blindly on request. The consult is
where you explain your thought process and plans so the specialist understands the context for the request clearly.
S:
subjective
Chief Complaint
Explain what led the patient to seek
care, using their own words
O:
History of Present Illness
objective
(Onset, Location, Duration, Character,
Aggravating/alleviating, Radiating, Test
results [cold, percussion, palpation,
radiographs], Timing)
OLD CARTT
Medical History
Does it relate to the CC?
Would it affect any future tx?
Medications
Know why all medications prescribed.
Know how they might affect any
planned treatment.
Allergies
If allergic to medication, list the type
and severity of reaction. If
environmental, know when last
event, how managed. Hospital?
Social History
Include info that would bear on
treatment- anxiety, family situation,
“issues” and expectations.
Exam
What are the pertinent findings that
led to the referral?
A:
assessment
P:
plan
Diagnosis
Clear description of a disease process
for tooth or tissue
Treatment Plan
What do you want them to do?
 An opinion? “Evaluate for…”
 A treatment? “Evaluate and (tx)”
 Not sure? “Eval and tx as appropriate”
Make it clear whether you just want
an opinion or want them to perform
a treatment!
Overall Tx Plan includes:
Planned final restoration of this area is (ie, Fixed, Removable, Implant):
_______________________________________________________
The reason for the consult is that I’d like (choose and complete one):
 an opinion on______. (Ask specifics. Are implants feasible here? Require bone
grafts? Does this endo need to be retreated before FPD? Would Ortho help here?)
________________________________________________________________
 for you to evaluate the patient and perform ____________ procedure.
________________________________________________________________
 for you to evaluate _______situation and treat as necessary. (This should be used
prudently- it is a blank check. Normally you should have an idea of what you want.)
__________________________________________________________________