OR Playbook
Step 21 · Preop & Exam

Presenting Your Patient

How to hand off your H&P and plan to your attending — clearly and confidently.

4 min read

The TL;DR

  • A clear presentation builds your attending's confidence — and earns you more hands-on cases.
  • Open with a one-line summary sentence, then go SOAP or by organ system.
  • Lead the objective/exam with the airway exam — it's what anesthesia cares about most.
  • End with your anesthetic plan; early on, 'general vs regional, then I'll take your guidance' is a fine plan.

01The structure

Communication is a core anesthesia skill, and it starts with how you present. Open with a summary sentence, then use one of two formats.

Summary sentence: > "This is a ___-year-old [man/woman] with [no / a significant] past medical history of ___, here for ___ surgery."

SOAP: - Subjective — the history. - Objective — the exam; start with the airway exam, then the rest. - Assessment — pull the H&P into a picture of the patient. - Plan — your anesthetic plan.

Or by system: summary sentence, then airway → cardiac → pulmonary → GI → endocrine → neuro → other, then the plan.

Pearls
  • Lead the objective with the airway — it's the first thing your attending wants to hear.

02The plan (it's OK to be junior)

End with your anesthetic plan. When you're new, you may not have a detailed one yet — that's fine. State the big choice ("I plan on a general," or "a regional") and ask your attending to guide the specifics. As you gain experience, the plan gets sharper and the presentation gets faster. A confident, organized hand-off is what earns you more procedures and patient care.

Concepts adapted for AnesthesiaHub from “Anesthesia Made Easy” (Jeff Steiner, DO, MBA) and standard anesthesia references, re-expressed in this site's own words. Educational use only — always verify doses against primary sources and your institution's protocols.