Instructions for Write-ups

The Medical Write-Up

NEW 2020- Social Determinants of Health (SDH) screening opportunities are highlighted. Not all SDH domains are included. There are many natural places in the interview SDH can be addressed.

“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.”

Abraham Verghese
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.
  • Follow a logical chronology
  • Avoid using unconfirmed diagnoses in the HPI
  • Report physical examination findings (not diagnoses which belong in the assessment
  • Abbreviations are permissible as long as they are not ambiguous and are of standard acceptance.

The Chief Concern (This is the “title” of your story.)

There are different styles, choose what works best for you (or what your attending prefers.)

  • For the purist, this is the patient’s own words in quotations.
  • Common modification to “purist” approach provides the basic patient demographics, the patient’s own words (possibly edited a bit) and the duration. (e.g. 46 yo m w/ “a stabbing pain in my back” for 2 days)
  • For the patient unsure why they are here or can’t communicate- CC is the physician’s reason for admission. (e.g. “Mr. Jones is referred for admission by his nephrologist for treatment of acute kidney transplant rejection.”)
  • Another acceptable format: Mr./Ms. (name of patient) is a (age)- year-old (gender, occupation), who is admitted to the hospital for the ___th time with a chief concern of “(symptom, not a sign or diagnosis)” of ___ duration.

DO NOT list a patient’s PMH before giving the chief complaint

  • Does not allow the reader to “select a program” in which to organize their thoughts.
  • If some 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 concern.

  • Organized in relation to the date of admission (4 days PTA…) or first onset of relevant symptoms (In 1996…).
  • NEVER begins with a list of PMH
  • Be specific when describing symptoms,
  • Use the patient’s own words whenever possible and quantify whenever possible. (‘Mr. J could walk a mile one month ago without getting SOB, 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 obtained from a chart review, outside records, or a referring physician should fit into the HPI.
  • It is acceptable to refer to confirmed diagnoses made by other physicians in your HPI.
  • 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, reserve your diagnostic impression to the ‘assessment’ portion of the write-up. (Just because a “doctor” gave a diagnosis, don’t assume it is correct. Keep your mind open.)

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.’

Pertinent positives and negatives (i.e. symptoms relevant to your differential diagnosis)

  • Can be included in a separate paragraph after the description and elaboration of the symptoms.
  • Most pertinent positives easily fit into a well-organized narrative and do not need to be listed separately.
  • Pertinent negatives are factors that, if present, would have suggested a different diagnosis.
  • Symptoms included in the HPI do not need to be listed again in ROS

HPI does not include a section called “ED course”

  • If the patient reports something tried in the ED affected their symptoms, then that is history included in the HPI.
  • If an unexpected finding in the ED is the reason for admission then you can mention that in the HPI.
  • Lab, imaging, and other objective data belong in that section of the write-up.

Finally, you should ask 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) and record it if relevant.

SDH Opportunity- Financial concerns frequently come up when asking how the illness is affecting the patient’s life. Are you concerned about losing your job? Are you concerned about how you will pay for your medical care?

The Past Medical History (PMH)*

  • Past disease and illness, not symptoms.
  • Typically documented as a numbered list.
  • Include major diseases (conditions followed by a doctor), OB/GYN hx (LMP, pregnancies, childbirth experiences), hospitalizations, and operations.
  • 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

  • Traditionally listed after PMH because easiest to see how the diagnoses and medications relate (patients often forget diagnoses until you ask the reason for a medication)
  • List dosages (if unknown, note that)
  • Include OTC and supplements
  • Electronically imported medication lists should ALWAYS be edited with all supplies and other non-medications removed
SDH Opportunity- Do you have concerns about being able to afford your medications?

Allergies

  • 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. (Pneumonia & flu are still one of the 10 leading causes of death in our country!)

The Family History (FHx)*

  • First -degree relatives is the minimum.
  • Routinely ask about common conditions with a genetic component (e.g. CAD, HTN, breast cancer, colon cancer, diabetes, prostate cancer, high cholesterol, depression, alcoholism).

The Social History (SHx)*

 A thoughtful social history demonstrates the curiosity and humanism present in “master clinicians”.

Most relevant to inpatient:

  • Marital/relationship status
  • Living situation- do they have stable housing, who lives at home (including pets), and do they feel safe?
  • Social supports- who could help them with ADLs, IADLs if needed, do they need help with transportation?
  • Education level, English first language
  • Occupation(s)
  • Habits (tobacco, alcohol, drugs- include amounts)
  • Diet- including food insecurity
  • Activity- including mobility limitations and fall risk

We strongly encourage learning about your patient’s daily activities, hobbies, and interests. (If you do this consistently, one day this information will give you a key insight into a patient’s diagnosis. Also, it shows you care and will engender trust.)

SDH Opportunity- A good SHX addresses SDH, which is very relevant to planning a successful transition out of the hospital. Concerns raised in the SHX can be elaborated with formal screening tools.

*Effective Documentation in the EMR: Avoiding “Note Bloat”

The EMR has separate sections for all historical data except the HPI and ROS. For patients who already have those sections populated with data, it is efficient to update (and correct) this data rather than repeat it all in the note. In your note you can include only what is relevant to the current admission (or visit in an outpatient setting). (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”

This requires a much higher skill level than just dumping everything in the note. Are you up to the challenge?

The Review of Symptoms/Systems (ROS)

  • 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).
  • List all positives (not already covered in HPI).
  • Potentially serious positive findings require elaboration. (E.g. patient with cough during the ROS mentions black, tarry stools, you shouldn’t merely list “black, tarry stools”. You need to elaborate on this (perform a 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. The physical exam traditionally is presented in head to toe order with neuro coming last. (Refer to Bates.)

Three common mistakes:

  1. 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.
  2. 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’.)
  3. 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).

Laboratory Data

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 Assessment

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 concern, then very select findings that support your to the leading 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 alcohol-induced pancreatitis.”

You would then follow this summary statement with a brief paragraph addressing any findings that might point you away from your leading diagnosis and other diagnoses you are considering and why (the differential diagnosis). The more certain you are of your leading diagnosis, the shorter this discussion will be. Conversely, many times you will not be certain of the leading 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. There is always some uncertainty in medicine.

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 and often only 2-3 diagnoses are seriously being considered and merit discussion in the write-up.

Integrating related problems under a unifying diagnosis demonstrates a higher level of understanding and creates more succinct, readable notes. So instead of discussing cough, shortness of breath, leukocytosis, and infiltrate on CXR all separately, if you think your patient has pneumonia, then address these all together under that leading diagnosis.

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

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.

SDH Opportunity- Most notes conclude with a “discharge planning” section but it rarely addresses SDH. EVERY PLAN SHOULD INLCUDE A SDH SECTION with any needs you identified and who will help. Usually this part of the plan requires collaboration with a social worker, case manager, and/or pharmacist so the physician (student physician) can focus on the biomedical problems.

Assessment/Plan

Most 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.

The Problem List

This is a list of all a patient’s active health problems and is a separate section of most electronic medical records, 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.