Patient Write-up for Clinicals
nstructions for Patient Write-up:
-Write-up should be on a patient who is a 3-year-old boy who is admitted at the request of their primary care physician for a high fever and suspected meningitis. The patient’s mother is the source of the history.
-This write-up is for pediatric medicine
1.CHIEF COMPLAINT
-Include patient initials, age, chief complaint with duration (each worth one point).
2.HISTORY OF PRESENT ILLNESS
-Introductory sentence with patient descriptors
-Pertinent pre-existing conditions or past medical history
-Problem onset date or days prior to admission
-Character of Symptoms
-Duration of Symptoms
-Location and Radiation of Symptoms
-Quality of Symptoms
-Aggravating Symptoms
-Alleviating Symptoms
-Associated Symptoms
-History of previous treatment
-Pertinent positives included
-Pertinent negatives included
-Impact of Illness on patient and patient’s family
-Patients’ perspectives or beliefs on the illness
-Overall flow of history documentation
-Synthesis of HPI information
3.PAST MEDICAL HISTORY
-Complete list in reverse chronological order
4.PAST SURGICAL HISTORY
-Complete list in reverse chronological order
5.MEDICATIONS
-Med name, dosage, quantity, route, and frequency. Include over the counter (OTC);
herbal meds Accepted abbreviations ONLY (i.e. daily, not qd)
6.ALLERGIES
-Medications Food / environment allergies Type of reaction
7.Last normal menstrual period (LNMP)
-LNMP date written.
-(Male patient: write N/A)
8.FAMILY HISTORY
-(Mother, father, siblings. Ages given; and alive or deceased listed)
9.SOCIAL HISTORY
-(Support systems Habits (Tobacco / ETOH use, etc.) Work & Hobbies
10.Sexual History
REVIEW OF SYSTEMS
-General:
-Skin:
-HEENT:
-Neck:
-Breasts:
-Pulmonary:
-Cardiovascular:
-Gastrointestinal:
-Genitourinary (includes pregnancy for women):
-Peripheral Vascular:
-Musculoskeletal:
-Neurologic:
-Hematologic:
-Endocrine:
-Psychiatric:
11.PHYSICAL EXAMINATION
-General assessment
-Vital Signs (Temperature, Pulse, Respiratory Rate, Blood Pressure, Height, Weight, Pain Scale). *All must be listed for full credit.
-Skin
-HEENT (Head, Eyes, Ears, Nose, and Throat)
-Neck
-Lymphatics
-Pulmonary Exam
-Cardiovascular
-Abdominal Exam
-Musculoskeletal Exam
-Peripheral Vascular exam / Extremities
-Neurologic Exam (includes MSE)
-Breast
-Genitourinary Exam
-Rectal Exam – comment “deferred”
12.LABORATORY DATA
-Chemistry
-Hematology
-Urinalysis etc.
13.Radiology
-XRAY/CT/MRI EKG reported in the standard format
14.Differential diagnoses listed in sequential order as it pertains to chief complaint
-List 3 differential diagnoses, and have them listed in sequential order with supporting information for other active problems Includes pertinent history, PE and lab data to support differential diagnoses
15.Treatment Plan
-Therapy: Rx
-(Med. name, dosage, quantity, route, & frequency)
-Medical therapy, non-Rx (Life-style changes, Physical Therapy, etc.).
16.Consultation / Integration of Care
-(Cardiologist; Wound Care Nurse; Nutritionist), etc.)
17.Psychosocial Treatment plan (Social Services; Home Health Care, etc.).
-Patient / Family Education
18. Disposition / Follow-up plan
