Episodic Write-up: Episodic visits are mostly encounters that involve one-time visits (sometimes with a short follow-up depending on the diagnosis/existing comorbidities) or occur occasionally. Episodic visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected. Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.
This write-up should be 2-5 pages (excluding title page and reference list) and concentrate on the most pertinent information. Not all the systems or sections will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best/most important tools and information to justify your critical thinking.
Comprehensive Write-up: Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam (may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc. Episodic Write-up
You must know how to delineate which visits are episodic versus comprehensive. Conducting a comprehensive exam on a patient whose chief complaint and ROS support an episodic visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning/judgment (diagnosis/plan of care) if they perceive you are all over the place! Insurance is not going to pay you more because you decided to complete a comprehensive note on an episodic visit or diagnosis!
Alternative Write-up: Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process. These write ups will follow the same guidelines as comprehensive-write ups.
This assignment is designed to promote the development of the following: AACN Essentials (2022): Domains 1, 2, 4, 6, and 9 and NONPF NP Core and Population-Focused Competencies (2012;2017): Scientific Foundational, Practice Inquiry, Technology and Information Literacy, and Independent Practice. Episodic Write-up
Case Write-up Outline
Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.
Subjective:
CC: This should be in quotes: “I’ve had a cough and sore throat for 2 days”
HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.
Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.
Past Hospitalizations: Past hospitalizations with reason for admit, duration of stay, and rough dates
Past Surgical History: Past surgeries and rough dates when possible. Episodic Write-up
Medications: List name, dose, frequency and indication (why are they taking it?). Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history. If a patient is taking Metformin and there’s no related information on the history and/or diagnoses list, something is missing.
Allergies: Medications, Food allergies when applicable. Specify what type of reaction next to the allergy if known by the person you are collecting history from (E.g., Penicillin-rash)
Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For pediatrics: list dates for all immunizations.
Other pediatric considerations: list who all lives in home with patient, how many siblings with ages next to them, type of home, any pets inside/outside home & what type of pet, any smoking in home, any guns in home; if young child: are they in daycare or if babysitter or family member or parent stay home with child, are they in school & what grade and what type of grades the child makes, list any extracurricular activities, any problems with school or teacher, any recent social or home changes. If they are pre-teen and older- add alcohol use, smoking, sexual history, work history, etc.
Family History: It is generally appropriate to go back at least two generations. State family member (mom/dad/maternal grandparents/paternal grandparents/siblings/etc.), their age & if they’re alive, write unknown if history not known, write any conditions or illnesses next to each person, if they are deceased write deceased and any illnesses/conditions for them also.
Obstetrical History: When appropriate, document number of pregnancies and other relevant information.
Birth History – applicable for pediatric write ups especially for young pediatric patients
Review of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. Nutrition should be addressed, especially in pediatric patients. In childbearing women (any teen or female who have reached menarche), make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy). Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit). For a young teen you can put “not sexually active” (but make sure you have asked). This is sometimes tricky with teens being seen for general health problems but so very important. If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.
Objective
Vital signs (BMI should be included on every visit)
Physical examination
- Episodic exam: make sure that you detail your findings for each system pertinent to your Chief Complaint. E.g., if you have a child pulling on their ears, it will NOT look good if you do not document an ear assessment or otoscopic examination in your physical exam for your write-up.
- Comprehensive exam: This is head to toe detailed and thoroughly describe findings within ALL systems.
Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.
Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results. Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section. Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.
Assessment
List both your differential diagnoses and your presumptive diagnosis – include appropriate ICD-10 codes for all diagnoses. Remember that these should be supported by findings in your history and physical exam. For a comprehensive visit, you should document at least three ICD code diagnoses. Occasionally, a comprehensive visit merits a differential diagnosis list. If your ROS or physical exam findings reveal abnormalities, the abnormalities need to be addressed.
Please remember support your indicated diagnoses with evidence-based reference: provide citation and supportive information.
Plan
Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed. Please be sure this information is organized under each diagnosis; keeping it organized helps the write up flow well to where the reader is able to get a clear picture of everything you did during the patient encounter.