Every new patient requires a complete H&P. (Two new patients/week = minimum 16). Final requirement for the clerkship is to select your 4 best write-ups for submission. They will be part of your final clerkship evaluation and grade. They must be HIPAA compliant. If they are not, one point will be subtracted from the evaluation.
The Clerkship Directors determine competency. The IDEA evaluation checklist is used for evaluation with the additional consideration of overall effectiveness. Notes that contain overly detailed and textbook-like rather than patient specific discussions, will have one point subtracted.
Your peers and IM coach will give feedback on the write-ups. If you want your attending to give you feedback on your write-ups, ask them how they would like to do this. If for some reason your attending has a problem with the way you are taught to do a write-up, please refer him/her to the Clerkship Directors so that you do not get penalized (or find yourself writing two versions, which is not acceptable).
The format used for H&P’s is the traditional one taught in ICM, Bates, and most US medical schools. Detailed instructions are in the links below and in the menu. It is expected that you will need to do some reading to formulate your differential, assessment, and plan.
Timeline for an H&P:
- Record the history, physical exam, and labs immediately after obtaining them. (Tip: if you find you forgot something, go back and do it, and incorporate it into the H&P. No one will know you forgot.)
- Read about your leading diagnosis and other aspects of the presentation you need to learn about that day/evening
- Write your assessment and plan before rounds the next day
- Review with a peer for feedback using the IDEA evaluation tool
- Select at least two H&P (one per 4 weeks) to review with your IM coach
- Apply feedback to the next H&P
Peer Feedback: There will be dedicated noon conference times for you to pair up with a member of your teamlet to give feedback using the IDEA evaluation form. A clerkship director will be available for questions and most of these sessions will have teleconference capability for students in Jacksonville. You may make edits based on peer feedback.
You are not allowed to edit and resubmit a write-up that has already received feedback from a faculty member. This is not a good use of your time and we are more interested in seeing if you can apply the feedback in a new setting. You are welcome to submit write-ups that include the track changes feedback some coaches use.
Perfection is not the goal. Missing minor details, minor organization problems, grammar issues will not affect your grade. Missing major aspects of data collection (e.g. incomplete physical exam), a difficult to follow narrative in the HPI, and/or giving an unclear working diagnosis and/or clinical rationale are problems that could affect your grade. Going overboard in your discussions leading to excessively long write-ups that are not practical to write or read also may affect your grade.
In addition to formal instructions, we have provided multiple examples of write-ups below to help you understand the expectations.