A formal write-up will be purposefully more detailed than the admission history and physical in the chart to demonstrate the students ability to concisely, accurately and with sufficient detail, REPORT all elements of the initial patient history and physical examination.
The student write-up will also include a succinct summary statement and problem list followed by an assessment and plan for each problem demonstrating their ability to INTERPRET the data and MANAGE the problems with a discussion of their diagnostic and therapeutic decision making when appropriate.
The student can EDUCATE by sharing an evidence based approach in their assessment.
The student should use initials in replace of any names in the write-up for reasons of confidentiality.
Below is an in-depth explaination of each write-up component.
The chief complaint should be one sentence that introduces the patient and clearly states the patients main reason(s) for seeking care, stated verbatim in quotation marks whenever possible, and should include the duration of the problem.
Once you have completed your entire history and physical examination and reviewed any records, labs, medical tests and imaging available at the time of your examination you should present the history of the patients present illness in a chronological, logical and organized manner that reflects your understanding of the course of the patients illness and is easy for the reader to understand and follow. Specifically the history of present illness should:
Tell a chronologic and organized history that begins at baseline.
For many patient presentations, to understand and evaluate the patients current symptoms and history it is essential to establish the patients baseline medical condition. This would include:
Appropriate use of the 8 cardinal descriptors of each symptom:
The eight cardinal descriptors of a symptom are used to help better appreciate the natural history of a problem and explore the differential of its etiology. For the main symptom(s) of the patients problem and to a lesser extent other symptoms he/she may be having you should use the cardinal descriptors to probe and subsequently describe their history. An appropriate use of the descriptors is expected but at a minimum, four out of the eight should be used for the main symptom(s).
Appropriately includes pertinent positives and negatives, exploring the chief complaint in a way that reveals the students working differential diagnosis.
As you are actively obtaining the history from the patient you should be developing and modifying a differential diagnosis of the patients current problem and obtaining any other data that may be significant to the patients current condition or the subsequent work-up or treatment of that problem. As you take the history from the patient you should therefore be doing a focused review of systems that will obtain pertinent positives that will support certain diagnoses in the differential and pertinent negatives that will refute certain diagnoses in the differential. This focused review of systems can be placed, dispersed in logical places throughout the history of present illness or placed at the end of the history of present illness. Either way it will reflect your differential diagnosis and likely answer the question that the reader is pondering as they are doing the same. The specific points reviewed would not have to be repeated in the formal review if systems.
Appropriately incorporates other aspects of the history into the history of present illness (i.e. PMH/SH/FH).
With many problems there will be aspects of the past medical history, social history and family history that belong in the history of present illness. This pertains to the idea of providing the past medical history of a particular problem the patient has if they are presenting with a new complication or exacerbation of this problem in the beginning of the history of present illness to set the baseline and provide the context in which this current episode is happening. The detail in which it is presented is determined by the particular case but specific details can always be presented in the past medical history section. Often aspects of the social history describe risk factors for certain disease processes such as tobacco abuse for COPD and CAD and alcohol abuse for liver disease. Likewise the family history can do the same such as a family history of colon cancer in a patient presenting with weight loss and bloody stools and a patient with a family history of CAD in a patient presenting with chest pain. These should be mentioned in a manner to set the baseline or context in which the current symptoms are occurring. The social history can also provide other aspects that may be pertinent enough to mention in the history of present illness such as code status, psychosocial support and level of functioning with activities of daily living and independent activities of daily living. Again these points would not have to be repeated in their respective section.
Once you explained the patients new problem(s) or complication/exacerbation of an existing problem you need to document the patients chronic and previous medical problems and general health care. In this section you can go into greater detail about chronic problems mentioned in the history of present illness.
Usually it is more coherent to organize the past medical and surgical history together. For example, mentioning cholecystectomy in the past surgical history and no mention of the reason or course of that illness in the past medical history is not acceptable. Did the patient have gallstone pancreatitis, cholecystitis or biliary colic and an elective procedure? Instead, for example, mention, cholecystitis status/post cholecystectomy, in the past medical/surgical history and a complete description of the course of this illness.
The past medical/surgical history should be organized in a logical manner according to the severity of illness, relevance to the current problem and in a manner that is keeping with the naturally history of the patients problems. For example:
In this section you should also mention obstetric and gynecological health and illnesses including pregnancies, their course and complications.
Psychiatric illness should also be mentioned in this section including course and hospitalizations.
The patients health maintenance should also be mentioned in this section including immunization status, screening tests performed and their result. For each bullet in the past medical and surgical history the problem should be:
Appropriately detailed and prioritized including:
A general description of how long the patient has had this problem or when the problem was first diagnosed. Can be an approximation or can be very specific. The course of the illness should be explained including treatment history, hospitalization or procedures/surgeries. The treatment history will include the current treatment regimen mentioning the medications currently used. Only mention the name of the medication. Test results that have been obtained in the past to monitor this illness or complications can be mentioned in this section also.
If the problem has symptoms associated with it these should be described appropriately in this section also.
Any complication that has resulted from the problem can be mentioned in this section along with its course, symptoms and treatment.
Appropriate detail to allergies (nature of adverse reaction):
A complete list of all the patients allergies and adverse reactions should be mentioned in this section. All drug allergies should have a description of the symptoms, signs or complications associated with the use of the drug in the past.
Proper detail to med list (dose, route, freq).
A complete list of medications should be listed including the dose, route it is given and frequency. This is a simple list for quick reference and no other information should be included.
All medications are accounted for by problem in HPI/PMH.
Reviewing the medication list the reader should not come across a medication that the
patient is taking that is not accounted for by a problem that is mentioned in the history of present illness of past medical history and surgical history.
Explores unhealthy as well as healthy habits with sufficient detail.
This section should include any habits the patient has that may influence his/her health or medical problems and specific details in regards to these habits. If fully explained in the history of present illness in regards to the patients presenting problem it does not need to be repeated. Tobacco abuse including smokeless tobacco, alcohol and CAGE questionnaire responses and drug abuse history including type of drug and route of administration should be specifically mentioned when appropriate. Any complication with the law in regard to illegal drug use or alcohol use should be mentioned if available. If the problem with alcohol or illicit drugs is severe enough to warrant a medical diagnosis then it should, instead, be mentioned in the past medical history along with its course, complications and treatment history if any. Diet and exercise or exercise capacity may be mentioned in this section when appropriate. A sexual history may also be mentioned in this section when appropriate including high risk behavior and contraception used. Explores other psychosocial aspects pertinent to clinical scenario.
With many patients it is important to obtain and document the patients living environment (i.e. house, apartment, shelter, homeless, assisted living, nursing facility) and who lives with them and helps care for them. This may include marital status, , family support and skilled nursing/health aid support. It is often important to assess and document the functional capacity of the patient in regard to their ability to perform activities of daily living (ADLs) which include walking, feeding, bathing, transferring from bed to chair and back, urinary and fecal continence, toileting and dressing and undressing and their ability to perform instrumental activities or daily living (IADLs) which include preparing meals, going places beyond walking distance, grocery shopping, doing laundry, managing money, taking medications using the telephone and doing housework. At times it is important to also mention the advanced directives the patient has in place including DNR/DNI and other specifics such as artificial feeding and who is the patient healthcare proxy if so named. Military, occupational and cultural background can also be mentioned in this section when appropriate.
Appropriately explores medical histories of family members.
This section should include the major health problems and genetics disorders in family members. First degree relatives including siblings are of the highest priority. Pertinent negatives can also be mentioned in this section. In certain disease states such as colon cancer, heart disease and breast cancer the age of onset for the problem is important.
Appropriately explores for co-morbid problems considering the particular patient.
In this section you should inquire about and document any symptoms/signs the patient is or is not having in an attempt to screen for any co-morbid disease the patient may have. This would require consideration of the specific patient and problems he/she may be at risk for (i.e. prostate problems in an older male, STDs in a promiscuous young male). There are 14 categories in a review of systems as listed below. You must appropriately use these categories considering the specific patient and must cover at least 10 to be considered a complete review of systems. This should not be approached with a generic list of symptoms/signs pertaining to a system but, instead, with the consideration of a disease first and then the symptoms and signs that may be associated with it. If the review of systems for a particular problem is significant enough to be considered a new or co-existing problem then it should be mentioned in the history of present illness as a co-existing problem coincidental to the presenting problem. The review of system categories are as follows:
Physical exam explores differential diagnosis adequately.
The exam should include the basic inspection, palpation, auscultation and percussion of the various body systems and areas but should also focus in on these body systems and areas considering the particular problems the patient has and include physical exam tests, procedures and maneuvers that would help work through the differential diagnosis, for example, performing orthostatic blood pressure readings in a syncope patient or patient with dehydration, the Dix-Hallpike maneuver in a patient with vertigo, carotid massage in a patient with syncope and palpating the epididymis and prostate in a male with fever of unknown origin.
Provides adequately detailed description of patient (could be pick out of line-up).
The exam should be a description of the particular patient as best as possible including inspection, palpation, auscultation and percussion of the various body systems and areas.
The exam should not be a simple list of findings that are not present.
Exam organized in logical manner with appropriate number and use of body systems/areas.
The exam should include the following body systems/areas. These are the only systems you should use. You should use as many systems as appropriate given the particular patient and problem(s) he/she has or may have but should at least contain 9 body systems/areas to be considered a comprehensive examination. For many complex patients being admitted to the hospital approximately 11 body systems/areas is likely more appropriate.
Constitutional (Vitals and General appearance)
Ears Nose Mouth Throat
Head and Neck
Palpation of lymph nodes in two or more areas:
Labs/medical test/imaging that is appropriate and sufficiently detailed.
Labs: All current lab studies on the patient should be documented with abnormal values highlighted.
Medical tests: Pertinent medical tests such as ECGs and EEGs should be documented with a full description of the result. This is especially true for ECGs where a complete reading of the ECG with comparison to old ECGs when available will be expected.
Imaging: All current imaging of the patient should be documented with a complete description of the result.
Only results from the current work-up should be included and results from previous labs/studies would be placed in the HPI and PMH as appropriate.
Once the history, physical exam and labs/medical test/imaging have been performed or reviewed, all of the subjective and objective information has been obtained and the process of diagnosing and managing your patients medical problems can begin. The problems themselves as well as the clinical reasoning used to identify/diagnosis and manage these problems must be documented in a manner that displays your diagnostic and therapeutic medical decision making. The process utilizes critical thinking and clinical judgment to:
Summary succinctly and appropriately pulls together the major points.
The summary statement briefly, in one paragraph, summarizes the pertinent positives and negatives from the history, exam and labs/medical test/imaging.
The summary statement documents the end result of steps 1 and 2 above. Essentially organizing and prioritizing the subjective and objective information attained. It restates only the important information that will be used to form clinical opinions and identify new problems as well as chronic problems that will require continued management. The summary statement briefly summarizes the pertinent positive and negative information from the history, exam and labs/medical test/imaging thats value and significance will impact your clinical opinions and problem list. The focus of the summary statement will be the main problem or chief complaint but will briefly include other new or chronic problems identified. For new problems with an unknown diagnosis this will document the information from the history, exam and labs/medical test/imaging that you used to narrow your differential diagnoses. This is demonstrated in the following graph:
Problem list is appropriately detailed (all problems listed).
The problem list documents the end result of steps 3 and 4 above. The processed subjective and objective information is used in the development of clinical opinions as to what the patients problems are and what is their priority. The problems should be as specific as possible and can include a diagnosis or working diagnosis if the evidence is convincing enough but can also include a symptom or sign, abnormal lab or imaging/medical test result when the diagnosis is uncertain and differential is broader and less defined. Symptoms, signs, abnormal lab or imaging/medical test results that, as a whole, form a diagnosis or working diagnosis need not be mentioned separately on the problem list. This would be explained in your medical decision making in the assessment and plan section. Remember, a problem is any diagnosis, working diagnosis, symptom, sign or abnormal test result that requires further management or attention and includes chronic problems.
The assessment and plan documents the end result of steps, 5, 6 and 7 above. It documents your medical decision making/clinical reasoning and has many important implications and purposes. It is where you document and explain for each clinical opinion/problem your hypothesis and hypothesis testing and the weight of evidence to support them. A hypothesis can be further thought of as a theory, suggestion or assumption about the diagnosis or treatment of a problem and the hypothesis testing would refer to the diagnostic plan or treatment plan to test that theory, suggestion or assumption. The assessment and plan must also consider the preferences of the patient. It is not easy to document your clinical reasoning. Consider that there are three models that try to explain how doctors perform clinical thinking/reasoning. The first is the linear model in which evidence that tend to support a diagnosis/treatment are assigned a positive weight and evidence that does not support the diagnosis/treatment are assigned a negative weight. The decision to discard or accept a hypothesis is based on the sum of the diagnostic weights. The second model is the Bayesian model in which physicians change their belief in a hypothesis about a diagnosis or treatment with each new item of information. The third and final model is the algorithmic model in which physicians follow an internal flow sheet with branching logic as they test a diagnostic or therapeutic hypothesis.
Discusses appropriately prioritized differential diagnosis for all undiagnosed problems displaying sound medical decision making.
For problems that have not been associated with a diagnosis a focused differential should be formulated based on the available information. The clinical thinking/reasoning involved in the formation of that differential should be explained.
Discusses medical decision making for all problems with appropriate level of detail
All problems on the problem list need to have the medical decision making involved with that problem documented. The extent of the medical decision making and the documentation will depend on the priority and clinical significance of the problem. New problems or exacerbations of chronic problems will obviously require a great deal of medical decision making. Stable chronic problems will not. The severity, stability or control of a particular problem should be mentioned when appropriate.
Explicitly describes treatment and /or diagnostic plan for each problem with appropriate level of detail including patient education and counseling.
The plan in regard to the diagnostic work-up or treatment of a problem should be explicitly and specifically documented. What specific tests that will be ordered as well as how this test is going to impact your medical decision making should be documented. The specific treatment modalities and medications should also be specifically documented including doses and routes. Any monitoring that will be requireeed will also need to be documented. The reader should be able to easily write a full set of orders for the patient based on your plan.
Entire History and Physical Write-up will be written in a readable manner with proper grammar and spelling.