Instructions for Write-ups
The Medical Write-Up
“This was a moment, this waiting on the threshold, that I would come to know well. One stepped into a limbus of time, a labium of space. This name on a new chart was like the title of a novel you had just bought, the jacket cover still pristine, the book new. Or else it was the title of an apocalyptic short story from an anthology of stories. The first paragraph had just grabbed you and you could not put it down.”
My Own Country (1994)
(Highly recommended reading)
Every patient has an interesting story to tell. The most successful write-ups are those that tell the story rather than report a list of facts. Be specific and descriptive with your language. Limit abbreviations to those of standard acceptance. (When in doubt, write it out.) The following is the traditionally and most widely accepted approach to writing the H&P. Refer to your Bates’ Guide to Physical Examination and History Taking, chapter 2 or Sapira’s The Art and Science of Bedside Diagnosis, chapter 4, for an outstanding explanation, with examples, of writing the case record if you would like further guidance. (Copies are available in Dr. Harrell’s office and the Medicine Library)
The Chief Complaint (This is the “title” of your story.)
For the purist, this is the patient’s own words in quotations. (If there is more than one CC, then you need more than one HPI.) Often physicians use a modified version of this by providing the basic patient demographics, the patient’s own words (possibly edited a bit) and the duration. (e.g. 46 yo wm w/ “a stabbing pain in my back” for 2 days) Sometimes patients do not know why they were sent to the hospital or cannot communicate. In this case the CC is the physician’s reason for admission (e.g. “Mr. Jones is referred to UF by his nephrologist for treatment of acute kidney transplant rejection.”)
The following is another acceptable format: Mr./Ms. (name of patient) is a (age)- year-old (race, ethnic group, occupation, and/or very pertinent PMH), who is admitted to the hospital for the ___th time with a chief complaint of “(symptom, not a sign or diagnosis)” of (number followed by a unit of time) duration.
Avoid the VERY bad habit of listing a patient’s entire PMH before giving the chief complaint This does not allow the reader to “select a program” in which to organize their thoughts. If something in the PMH is relevant to the HPI, it can be introduced into the story when it is relevant rather than upfront.
BAD EXAMPLE: “Mr. Jones is a 53 year-old man with a history of COPD, HTN, DM, arthritis, tobacco abuse, GERD, hyperlipidemia, and pneumonia who is admitted with a chief complaint of “worsening leg pain” for the past 4 days.”
Comment on the source of the information and its reliability (in the CC or HPI ), if it is not obvious. Do not cover up lazy interviewing by labeling the patient “poor historian”. The label “poor historian” is a red flag for a poor interviewer. If the patient truly is a poor historian, you should provide a brief explanation of why (e.g. history limited by patient’s poor attention span).
The History of Present Illness (This is the story.)
The HPI should be a chronological history of the chief complaint. It can be organized in relation to the date of admission (4 days PTA…) or in relation to the first onset of relevant symptoms (In 1996…). Be specific when describing symptoms, using the patient’s own words whenever possible and quantifying whenever possible.
GOOD EXAMPLE: ‘Mr. J could walk a mile one month ago without getting dyspneic, but over the past month his DOE gradually progressed to the point that he cannot walk 50 feet without stopping to catch his breath.’
Information relevant to the CC obtained from a chart review, outside records, or a referring physician belongs in the HPI.
It is acceptable to refer to diagnoses made by other physicians in your HPI. However, you should reserve your diagnostic impression to the ‘impression’ (or ‘assessment’) portion of the write-up. (Just because a “doctor” gave a diagnosis, don’t assume it is correct. Keep your mind open.)
Pertinent positives and negatives usually are included in a separate paragraph after the description and elaboration of the symptoms. Most pertinent positives can easily fit into a well-organized history and do not need to be listed separately. Pertinent negatives are factors that, if present, would have suggested a different diagnosis. A general rule is to use pertinent positives and negatives only when they are relevant to your differential diagnosis. Parts of the PMH, FHx, and SHx that are pertinent to the present illness and differential diagnosis should be included in the HPI. Emergency room work-up rarely belongs in the HPI unless something occurred leading to the admission. (e.g. patient seen with foot pain in ED found to have hyperkalemia necessitating admission)
ED Course– Most things that occur the day of admission in the ED, do not belong in the HPI unless it changed the story. (e.g. altered mental status cleared after administration of narcan). Labs and tests performed in ED belong in the lab section.
Finally, you should include some comments about how this current problem is affecting the patient’s life and any specific concerns the patient may have (i.e. a patient with chest pain may have recently had a friend die of a heart attack).
The Past Medical History (PMH)*
A list of past disease and illness NOT symptoms- major diseases (conditions for which they are followed by a doctor), OB/GYN hx , hospitalizations, and surgeries. When possible, include the dates and location of the hospitalizations. Some medical conditions should have further details provided. (For example, for patients with CHF, it is very helpful to know when that had their last ECHO and what it showed.)
Medications and allergies have their own headings. All medications (including OTC and supplements) should be listed with the dosage. (As a student, it is an excellent idea for you to note what each medication is for, though you will not do this routinely in practice. It will help you learn the drugs faster.)
Allergies should always include a brief description of the reaction. (Nausea is not an allergy; it is an ‘intolerance’ or an ‘adverse reaction’ and should be listed as such.)
Preventive Health History*
Usually not part of inpatient note. Most preventive health issues that are pertinent would be included in the HPI (e.g. in a patient with weight loss, you would definitely want to include their cancer screening history…but in the HPI). Immunizations are the one area that should always be addressed, particularly the pneumococcal and flu vaccines in the elderly and immunocompromised as this is such a large portion of our patients. (Pneumonia & flu are still one of the 10 leading causes of death in our country!)
The Family History (FHx)*
You should obtain the FHx for a patient’s first -degree relatives at the minimum. You should also get in the habit of asking routinely about common conditions that have a genetic component (e.g. CAD, HTN, breast cancer, colon cancer, diabetes, prostate cancer, high cholesterol, depression, alcoholism). Usually this information can be listed. However, if there seems to be a disease that has affected several generations, a family tree may be a more efficient way to present the data. (The EMR does have a function that allows you to do this if it is your preferred method for documenting the FHx)
The Social History (SHx)*
This is one part of the write-up that distinguishes the above average students from the average. A thoughtful and detailed social history demonstrates the curiosity and humanism present in “master clinicians”. At the bare minimum, you should address the patient’s marital status, who is living at home, social supports, education, occupation(s), and habits (tobacco, alcohol, drugs, and sexual history). You are strongly encouraged to learn something about your patient’s daily activities, hobbies, and interests. (If you do this consistently, I guarantee that this information will give you a key insight into a patient’s diagnosis one day and make you look like a star. Not to mention your patients will like you better if they think you care about them and not just their disease.)
*As a medical student you are allowed to update the past, family, and social history in the EMR in their respective sections. Since much of this information is not relevant to the CC, you can highlight the information that will be relevant to the acute hospitalization. Some faculty will not like this but the advantage is you don’t paste in a lot of extraneous details (creating “note bloat”) like the tonsillectomy at age 3 and mother with osteoarthiritis, and even preventive health maintenance which is important overall but rarely during an acute hospitalization.
For example, you could write the following, “We reviewed and updated the complete past, family and social history in the EMR and details can be viewed there.
Past history is notable for 1. HTN 2. poorly controlled diabetes 3. chronic kidney disease with last GFR 44 5/2011.
Family history- see EMR
Social history- he still lives alone with few supports and continues to smoke”
The Review of Symptoms/Systems (ROS)
This is organized by organ system but is really a catalogue of symptoms. You do not need to list all the negatives (all pertinent negatives would be in the HPI already). All positives should be listed.
Elaborate on potentially serious positive findings. (e.g. during the ROS a patient mentions she’s had black stools, don’t simply write “black stools” without more details (mini HPI).
Do not repeat information you already included in the HPI or PMH here as it is redundant.
The Physical Examination (PE)
Vital signs Other than temperature, you should confirm the vital signs yourself. (They are vital.) Orthostatics or other special maneuvers like pulsus paradoxus are included with the vitals. NEVER list “obtain orthostatics” in your plan as you need to do it yourself as part of the exam.
General description of the patient. Try to provide a description that would allow your attending to go from room-to-room and identify your patient. Include pertinent observations related to the patient’s presenting complaint when applicable. (e.g. patient presents with shortness of breath- is he ‘lying flat with unlabored breathing’ or ‘sitting forward in the bed breathing rapidly through pursed, blue lips using accessory muscles’.)
The remainder of the physical exam follows the pattern of inspection, palpation, percussion, and auscultation as appropriate.
Three common mistakes:
- Inadequate description of findings, or worse, write ‘normal’ (‘WNL’=“we never looked”), or ‘benign’ without even specifying to which specific part of the exam they are referring. (For example, ‘HEENT- normal’. Should one assume that this includes a funduscopic exam?) Occasionally, it is acceptable to describe something as normal if it doesn’t beg further description.
- Performing the same exam on every patient. The physical exam should be tailored to the individual patient. If a patient is jaundiced or has known cirrhosis, you should specifically seek out stigmata of chronic liver disease and note their presence or absence. But for a patient with syncope, you don’t need to do that; rather, you should perform a very thorough cardiac and neurological examination. (It is very embarrassing to admit a patient with hip pain and forget to exam the hip because it is not part of your ‘routine exam’.)
- Performing an incomplete exam (screening neuro most commonly omitted) Elderly patients need a mental status exam performed. (Delirium is very common in the hospitalized elderly.) The MMSE (Mini-Mental Status Exam) and/or CAM (confusion assessment method) are validated screens.
“Deferred” means you plan to perform it later or someone else will be performing it.
If a patient declines part of the exam, then simply write “patient declined”.
If another physician already performed a sensitive part of the exam, like a rectal or pelvic exam and there is not a medical reason to repeat it yourself, you should document that physician’s findings attributing them to him/her (e.g. rectal with normal sphincter tone and brown, hemocult negative stool per Dr. Jones’ exam in ED).
List all the relevant** data that are available at the time you are formulating your differential diagnosis and assessment (wait for basic blood work and radiographs that come back quickly).
Read your own CXR and ECG
Do not include old lab data in this section (e.g. ECHO from 3 years ago. If it is relevant to the cc, put it in the HPI and if not, put it in the PMH.)
**In the era of the EMR when data is one-click away, you can make a compelling argument for not pasting into your note every morsel of lab data but rather highlighting what is most important to your assessment and plan. This requires a higher level of clinical reasoning and fund of knowledge, but give it a try.
The Problem List
This is a list of all a patient’s active health problems and is usually a separate section of the medical record and not part of the write-up. It should be complete, prioritized (when possible), and specific without being overly redundant. The problem list also is not static. If a problem resolves, it should be removed. Once a diagnosis is made, the problem should be updated to reflect that. For example, on admission a patient may be hyponatremic and that is listed as a problem. The next day the work up may reveal SIADH so the problem list will be updated to say SIADH. Later you may discover the SIADH is caused by lung cancer so you would add that.
This is the place where you commit to a diagnosis, provide insight into your reasons, and discuss the relevant differential. Many physicians like to provide an overview in a couple of sentences so someone can quickly see their assessment, called a summary statement. This is usually formatted with patient demographics, followed by chief complaint, then very select finding that lead to the working diagnosis. For example, “Mr. Jones is a 45 year-old man with alcohol abuse presenting with epigastric pain and an elevated lipase most consistent with pancreatitis.”
You would then follow this summary statement with a brief paragraph addressing any findings that might point you away from your working diagnosis and other diagnoses you are considering and why (the differential diagnosis). The more certain you are of your working diagnosis, the shorter this discussion will be. Conversely, many times you will not be certain of the working diagnosis. You should still commit to what you think is most likely and why but you will follow this with a more detailed discussion of your differential. You should discuss your differential in descending order of likelihood.
A good rule of thumb is that you should provide specific comments about anything in your differential that you are planning to evaluate or address in some way. You need only add a comment that ‘W, X, Y, and Z are unlikely but should be considered if the initial work up is negative’. Do not include things in your differential that you know the patient doesn’t have (e.g. splenic infarct in a patient with LUQ pain and remote history of splenectomy). It is very important to go through the exercise of generating as broad a differential diagnosis as you can for each patient. (This separates the master clinicians from the ordinary.) However, you do not need to include it as a separate list. It should flow as part of you assessment as described above.
For patients with multiple active problems, you need to address each problem. However, many of these problems may be related to prior diagnoses and, therefore, do not need a differential diagnosis and your detailed thought processes. They should be listed as diagnoses (not symptoms) with a brief comment about acuity. (For example, HTN- well-controlled, type 2 DM with poor control, hypercholesterolemia- untreated). “Cards” is neither a diagnosis, nor a problem. DO NOT ORGANIZE YOUR NOTES BY SYSTEMS NO MATTER WHAT YOU SEE OTHERS DO. In general, organizing by systems rather than problems and diagnoses leads to sloppy thinking because you lose sight of the symptom or problem you are treating and often do not prioritize the problems correctly.
The plan is typically a numbered list of any tests and treatments you are ordering. If you have done a good job conveying your thoughts in the assessment, the plan needs no further discussion as it should be obvious why you ordered what you did. Most patients on Internal Medicine have multiple active problems with their own plans. You can number all the assessments and follow each diagnosis by its own plan or keep all the plan separate.
Many physicians lump the discussion of the assessment and plan together particularly when patients have multiple problems and diagnoses. There is nothing wrong with this practice. However, at this stage in your training, most medical students tend to be quite redundant when doing this, which leads to extra work for you and unnecessarily long notes. Try keeping the plan(s) separate and numbered for now.