Guidelines for Write-Ups


 

Principles

The purpose of the write-up is

To record your patient's story in a concise and well-organized manner.

To demonstrate your clinical reasoning and decision making to other providers

To demonstrate your fund of knowledge and problem solving skills.

Although there is no single authority on write-ups, these guidelines will help you avoid common mistakes. Further specific feedback from your teachers will illustrate the diversity of styles used in the successful write-up.

 

The Length and Structure

The overall length should be 3-5 pages. Here is a suggested detail for each component of the write up:

Source of Information (1/2 line)
Chief Complaint (1-2 line)
History of Present Illness (1/2 to 1 page)
Past Medical History (list)
Family History (5 lines)
Social History (5-10 lines)
ROS (1/4-1/2 page)
Physical Examination (1/2-11/2 pages)
Laboratory (1/4-1/2 page)
Assessment/Plan (1-11/2 pages)

History of Present Illness (HPI):  The history of present illness can be viewed as a hypothesis generating statement.  The first paragraph should make clear to the reader the primary hypothesis (or hypotheses) that one is considering as an explanation of the patients presenting complaint(s).   The second paragraph should make clear to the reader the alternative hypotheses that one is considering by means of providing additional pertinent negatives / positives that may alternatively explain the patients presenting complaint(s).

The following is a basic structure of the HPI.

The Topic Sentence
The topic sentence should begin with identifying information. Include the patient's

Age
Sex
Country of origin or race if relevant
Other social/demographic info if relevant
Other active and relevant medical problems

- no more than four
- must be critical to understanding the chief complaint or will influence the management of the patient

Summary of the chief complaint

Good examples

''Mr. Jones is a 54 yo man with a history of a recent umbilical hernia repair who presents with nausea, vomiting, and abdominal pain.''
(acute and latent complications arise from prior abdominal surgery)

''Mrs Evans is a 62 yo woman with diabetes and steroid dependent COPD who presents with dysuria and hematuria.''
(diabetes and lung disease will require active management in the hospital)

Bad Example

''Mr. Smith is a 45 yo man with a remote history of diverticulitis who presents with a swollen leg.''
(diverticulitis is neither active nor relevant and belongs in the PMH)

Chronology

Next describe the story chronologically. If you believe that the chief complaint (chest pain) may be the direct extension of his ongoing chronic problem (recurrent PE's s/p leg trauma), then begin the HPI with the chronic problem.

''Mr. Womack is a 45 yo man with a history of recurrent pulmonary emboli (PE) who presents with chest pain. Two years prior to admission, he suffered a compound femur fracture from a motor vehicle accident. He course was complicated by a PE. He since has been treated with coumadin and has demonstrated noncompliance with the medication leading to two subsequent admissions for PE. He was in his usual state of health until,...''

Sufficient Detail

Pay attention to detail. The well-characterized history includes

Setting of the complaint
Intermittent/constant
Progressive/stable or improving
Any prior episodes
Duration
Aggravating or alleviating features
Associated symptoms
 

''...He was in his usual state of health until today when, while sitting in a chair, he developed the abrupt onset of a diffuse left anterior chest pain without radiation, associated with shortness of breath. The pain was 5/10, described as sharp and constant. It was unaffected by position.''

Pertinent Negatives

Include pertinent negatives so that the reader is influenced to think in terms of your differential diagnosis.

''...There was no fever, cough, sputum, chest pressure, nausea, vomiting, bloating, or hematemesis. He has no prior history of trauma to the chest, prior coronary artery disease or anxiety.''

The pertinent negatives reflect the differential diagnosis. Other causes of chest pain to consider in this case are pneumonia (fever, cough, sputum), coronary artery disease (radiating chest pressure, nausea), peptic ulcer disease (nausea, vomiting, hematemesis), anxiety or musculoskelatal disease.

Only negative statements belong in the pertinent negatives section. If you discover that your patient has not been taking his coumadin, you would tell the story chronologically.

''... He has not been taking his coumadin over the last three weeks. He was in his usual state of health until today when...''

If Evaluated Elsewhere and Transferred to Your Service

Key events from outside evaluations are placed in the concluding remarks of the HPI.

''...Because these symptoms did not improve and were similar to prior PE's that he experienced, he went to his local physician who hospitalized him at St. Mary's Hospital. Evaluation there revealed a swollen left lower extremity, a sub-therapeutic prothrombin time and a moderate probability VQ scan. He was given the diagnosis of PE and transferred to our hospital for further evaluation.''

Relevant data collected before your evaluation (or the Emergency Department evaluation) even if it includes physical findings and labs, belongs in the concluding remarks of the HPI.  Alternatively, this data may be incorporated into the chronology for the patients HPI if it is relevant to the story and helps build the hypothesis being constructed in the first paragraph.

 

Past Medical History

Include all medical problems (active or remote). We suggest that you order the problems outline the problems from the most pertinent to the least pertinent to the issues of the current illness.

1. Recurrent PE's, see HPI
2. Noncompliance with coumadin, see HPI
3. MVA with left leg fracture
4. Cellulitis, group A streptococcal bactermia, no recurrences
5. Appendectomy*,
6. T&A as a child*

If Mr. Womack was admitted for lower abdominal pain with a differential including small bowel obstruction, then the appendectomy would take higher priority in the PMH listing and be mentioned in the HPI.

* You may list prior surgeries in a separate section or record them in order of pertinence to the current presentation with the other medical problems

Certain diseases require listing of pertinent positives and negatives in the PMH. Your residents can assist you.

1. COPD: diagnosed 1995, never required steroids, never intubated, hospitalized x 2 for exacerbations in (  ) and (  ), ( ) PFTs FEV1 1.8L, FEV1/FVC 0.65.
2. DM: diagnosed 1997, oral hypoglycemics, Hgb A1C 1999 8.2, no micro- or macro- vascular complications known.
3. CAD: s/p PTCA of LAD 1998, angina equivalent is chest pressure with exertion, 2 NTG tabs a month, cath 2000: 70% LAD stenosis, 30% circumflex stenosis, no wall motion abnormalities (or last echo showed,...)

Other items to include in the Past Medical History, as taught in physical diagnosis:

medications (record doses)
allergies (list reaction experienced)
substance abuse
transfusions
substance abuse
childhood illnesses and immunizations if pertinent

 

Family History

Construct a family tree. Specify whether there is a family history of DM, HTN, cancer, heart disease, or illness similar to the HPI.

 

Social History

Include social support, occupation, education, travel, and sexual history.

 

Review of Systems

Listing, rather than using subject and verbs, is preferred. Remember, pertinent positive and negative symptoms dealing with the present illness belong in the HPI, not the ROS.

 

Physical Examination

Listing, rather than using subjects and verbs, is preferred.

 

Laboratory Data

A commonly used order is:

Electrolytes
CBC
Urinalysis
CXR
EKG
Microbiology
Other

 

Assessment and Plan

When the differential is unknown

State the problem, which usually is a symptom, sign, or abnormal laboratory result or diagnosis. List a differential diagnosis. State which diagnosis is most likely and why, drawing from the information from your recorded history and physical. State why other diagnoses in the differential are less likely. Discuss the plan. ''I favor the diagnosis of PE because,... I believe that pneumonia is less likely given the CXR,...''

When the differential is known

Your discussion should focus on causes of the condition or controversies in management. Your resident or attending can assist you in tailoring the discussion to meet your learning needs.

When the patient has multiple problems to discuss

Again, your resident or attending can help you to determine how to organize you're A&P. For example, you have a patient with COPD, pneumonia, and uncontrolled DM. Since you have had many patients with COPD exacerbation, you decide not to discuss COPD. Instead, you argue that the pneumonia likely led to the COPD exacerbation and uncontrolled glucose readings, then you expand your discussion with a review of pneumonia pathogens in this population. You conclude with your plans to pursue further diagnosis (sputum culture) and provide therapy (bronchodilators, antibiotics, IVF's, and insulin).

 

 

Common Mistakes

Pertinent Negatives are Omitted - This section is difficult and requires that we thoroughly understand the differential diagnosis of our patient's complaint.

Related complaints are discussed separately in the HPI - A patent with expanding ascites may experience simultaneous dyspnea, abdominal pain, and edema. To discuss these three symptoms as separate problems in the HPI is a mistake. Ask for direction from your resident or attending if you are unsure whether symptoms are related.

Long narrative descriptions of physical signs - use listing, omit subjects and verbs.

Inattention to detail - A ''soft systolic ejection murmur'' is inferior to ''a 1/6 midsystolic murmur at the left sternal border, without radiation that decreases with Valsalva.''

List of unfamiliar abbreviations - When in doubt spell out the word.

Recording a diagnosis instead of a finding in the physical exam - Writing ''findings consistent with RLL pneumonia'' is inferior to ''right posterior base with increased fremitus, dullness to percussion and bronchial breath sounds.''

Incomplete Assessment and Plan - ''Hematemesis - probably varices. Plan T&C 4 units, 2 16g IV's, consult GI'' is only appropriate when you are an experienced house officer on a busy call night. As a third year clerk, you should become a scholar on your patient's problems and demonstrate this in your assessment, discussing a complete differential diagnosis, separating likely from unlikely diagnoses, and emphasizing a reason behind your plan.