Sample Write Up

Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 2

Evaluation of Student H&P UNC Medicine Inpatient Clerkship

Student Name: Date Submitted:

When Dr. Klipstein evaluates an H&P, he will consider the following issues:

History of  Includes a chief complaint


Present Illness  Appropriate dimensions of cardinal symptom are listed (including location, severity,
quality, setting, chronology, aggravating/alleviating, associated manifestations)
 Chronological story begins at baseline state of health
 Incorporates elements of PMH, FH, SH that are relevant to story (e.g. includes risk
factors for CAD for patient with chest pain)
 ROS questions pertinent to chief complaint are included in HPI (not in ROS section)
 HPI reflects knowledge of differential diagnosis
 HPI narrative flows smoothly, in a logical fashion
Past Medical  Includes sufficient detail (onset, complications, and therapy) for key diagnoses (e.g.,
History Type 2 DM, on pills since 1995, mild neuropathy, no known retinopathy/nephropathy)
Medications  Includes dose, route and frequency for each medication
 Includes over the counter and herbal remedies
Allergies  Includes nature of adverse reaction
Review of  Most systems are evaluated (e.g. Constitutional, HEENT, Respiratory, Cardiovasc,
Systems GI, GU, Neuro, Psych, Endocrine, Musculoskeletal, Hematologic/ Lymph, Skin)
 Does not include PMH (ex. Cataracts or heart murmur belong in PMH, not ROS)
 Does not repeat information already in HPI
 Adequate depth (e.g. GI: no abdominal pain, bloating, nausea, vomiting,
melena, hematochezia, change in color, caliber, consistency or frequency of stool)
Social History  Occupation, marital status
 Tobacco, EtOH, and substance abuse
 Functional status, living situation
Family History  State of health of parents, siblings, children
 Extended family occurrence of CAD, DM, HTN and cancer
 Age at diagnosis of important diseases, especially if premature onset (e.g. CAD in
brother age 37, colon cancer in father age 42)
Physical  Includes areas relevant to the chief complaint (e.g. for patient with cirrhosis includes
Examination presence/absence of stigmata of liver disease, for patient with CHF in differential
diagnosis includes presence/absence of JVD, crackles, murmur, gallops, liver size,
edema, etc)
 Does not include assessments/interpretations in PE section (e.g. describes “8x10cm
oval area of warm, erythematous skin on medial aspect of left thigh” instead of
“cellulitis on medial aspect of left thigh”)
Physical  Includes general description
Examination,  Includes vital signs (including O2 sats, orthostatics, and pain level when appropriate)
continued  Includes skin examination
 Includes lymph node survey (not limited to neck nodes only)
 Includes thyroid examination
 Respiratory includes more than “clear to auscultation”
 Cardiovascular includes assessment of neck veins, and distal pulses
 Abdominal examination includes measured liver span
 Includes rectal exam (or reasonable statement as to why not performed)
 Neurologic examination includes mental status, cranial nerves, strength, sensation,
cerebellar function and reflexes
Laboratory and  Includes lab data appropriate for HPI
Other Studies  Lab data adequately reported (e.g. includes intervals on EKG for patient with syncope)
Problem List  Includes all active medical problems
 Includes significant abnormalities in physical examination and laboratory studies
 Includes health maintenance/screening issues when appropriate
Discussion/  Includes sentence summarizing key history, PE and laboratory data
Assessment  Discussion is specific to the patient, not a summary of textbook or review article
And Plans  Adequate differential diagnosis reviewed for major problems
 Evaluation/diagnostic strategy proposed (or reviewed if already performed)
 Management strategy discussed
 Reflects an understanding of the pathophysiology of the patient’s illness
Style  Legible
 Not laden with spelling or grammatical errors
 Uses medical abbreviations appropriately, does not coin own abbreviations

Comments:

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy