Required H&P Write-ups Internal Medicine Clerkship

Internal Medicine is the practice of medicine relating to the care of adults. One of the most valuable contributions that an internist adds to the care of his/her patients is the organized and cohesive collection and analysis of data. In order for this to be useful, the internist must be able to communicate orally and in written form both the data collected and its assessment.

The clerkship requires three (3) detailed H&P write-ups:

#1 write-up is due at the end of week 2

#2 write-up is due during week 6

#3 write-up is due during week 11

The H&P write-up is a clinical exercise purposely more detailed than the admission H&P in a patient's chart:

more detail will insure that you are aware of and can demonstrate all elements of an initial patient evaluation
it represents the medical history and physical examination actually performed by you
the discussion includes a prioritized differential diagnosis for each problem (when appropriate) and is specific to the patient — it is what you think is going on not simply a summary of the literature
at the end of the discussion of each problem there should be a plan of what you will do to make the patient better
it must include all of the elements listed in the Vital Elements for H&P Write-ups Vital Elements Checklist - fill out while completing write-up
you need to have your senior resident or attending who also saw the patient, sign a patient validation form and you must submit one form for each write-up to the clerkship office Validation Form

Patient choice for your write-up is extremely important:

Bad patient choices:

transferred from another hospital
transferred from another service in the hospital (e.g. ICU)
the patient cannot give you a complete history due to dementia, intubation, etc.
you can choose a patient from your outpatient setting but the complaint/problem should be somewhat complex (e.g. common cold is too simple) — complexity counts because you want to learn something from doing the write-up

Good patient choices:

has a relatively identifiable complaint or problems that will teach you something
patient that has health maintenance or prevention related issues that need to be addressed especially in the outpatient setting

Evaluation:

#1 write-up is graded by a Grades Committee Member (GCM) who will meet with you to review
#2 write-up is graded by the same GCM who will return it to you with feedback; a meeting will take place only if requested by you or the GCM
#3 write-up is reviewed by a different GCM and it is done in a blinded fashion (GCM does not see author's name); #3 write-up is your final product upon which your write-up grade is largely based
form used by Grades Committee Member to Evaluate Write Ups

Citations:

follow guidelines on the Plagiarism handout in your orientation folder
no direct cut and paste is allowed from any source including standard texts
if the information you read is general and could be found in any IM text, you do not need to cite the source which you have consulted as long as the information is in your own words
try to limit your references/primary sources to 5 specific references per write-up
for specific information on how to cite UpToDate go to: http://www.uptodate.com/subscribers/user_manual/citing.htm.

Several Examples of Excellent Write Ups

Sample #1: chief complaint is "my heart was beating fast"

Sample #2: chief complaint is "I've been having bloody bowel movements"

Sample #3: chief complaint is "I've had a fever for the last eleven days and I feel lousy"

Sample #4: chief complaint is "weakness that I just can't take anymore"