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FORMAL PATIENT WRITE-UP (SUGGESTED OUTLINE)
(Note: MS-IV’s may dictate but MS-III’s may not)
1. Identifying data, date and time the patient was seen, and name of attending physician.
2. Chief complaint in words of patient, if possible.
3. History of present illness.
This usually should be written in the form of a historical essay. Frequent notations of elapsed time and time prior to admission should be included. The emphasis should be on the patient and the patient's symptoms rather than on the details of medical treatment, although sometimes these are of great importance.
As much as possible, this presentation should have dramatic impact and should be concise and comprehensive. Important negatives may be included.
4. General medical history and review of systems.
We expect you to review all the previous charts (now mostly on computer at DCH). This should follow the format you have learned: telegraphic style and plusses and minuses are OK to use.
5. Social history and occupational history should be investigated with emphasis on occupational exposure and other matters (social and family problems, etc.) as well as whether the patient drinks or smokes.
6. Family history.
The diagram of the family tree is often the clearest way to see family history, with a few extra words written in as indicated.
7. Physical exam.
8. Problem list.
Data are analyzed and a list of problems is generated, at the level which you understand them, not a speculative form.
9. Initial plans.
For each problem listed, initial plans are outlined. For example: Problem 1 - Headache
a. Diagnostic plans: What do you plan to do to establish the diagnosis? CT Scans? Lumbar puncture? Etc.?
b. Treatment: What treatment do you propose for the relief of the problem (analgesics, antibiotics, etc.)?
- Patient education: What do you recommend should be told to the patient and the family concerning the problem (diagnosis, prognosis, etc.)?
(Do this for each problem on your list.)
- In addition, medical students select a topic related to this patient's illness and discuss it briefly. This should not be a major topic, but an aspect of the patient's illness. If possible, it should be authoritative, but not exhaustive or encyclopedic.
The reference(s) should be current and listed in the write-up.
Three (3) formal write-ups are required to be submitted to an attending during the rotation. Turn these in within one week of admission. The grading for the write-up includes whether done on time. All write-ups must be submitted by the end of the fourth (4th) week of the rotation. |
