Appendix A

Suggestions on writing H&Ps and making oral presentations Adapted from the CDIM Primer on Internal Medicine Clerkships

Appendix A:

Suggestions on writing H&Ps and making oral presentations

Adapted from the CDIM Primer on Internal Medicine Clerkships

 

Writing H&Ps is an important skill and learning tool.  Think of writing your H&P as a means for integrating all of the information you gather with what you know and what you read to form a coherent, informed argument of what you think is happening with the patient, why, and what you want to do.

 

  • Use a clear and concise writing style.  Words that are not completely necessary are often left out…just the facts.
  • Write your history of present illness (HPI) to tell the story chronologically and with all relevant details.  When reading your HPI, the reader should be able to determine the diagnostic possibilities that you are considering and what is most likely.
  • Write in a way to identify information you forgot to gather.  Go back and get the information you need.
  • Document a thorough past medical history and complete medication list.  This step is essential to providing safe, high quality care, even though you may not always recognize why.
  • Document general appearance and vital signs.  Vital signs are vital.
  • Use only standard and widely accepted abbreviations; creative abbreviations confuse and slow the reader.
  • Never use dangerous abbreviations in the medication section (e.g., qd instead of  “daily,” μg instead of mcg, U instead of units, etc.).  A complete list of abbreviations prohibited by the hospital at which you rotate should be available to you.
  • Include laboratory data and results of diagnostic studies after the exam.  Do a complete ECG reading and document specific findings (or lack thereof) from radiologic studies (e.g., “CXR-no infiltrate or edema” is better than “CXR negative”).
  • Write neatly.  If no one can read what you have written, what good is it?

 

The assessment and plan (A/P) is always the most challenging and important section.  You may want to discuss your thoughts with your resident before beginning to write.  It is important to develop a complete, well-considered problem list for your patient.  List all active problems in order of descending importance.  Each problem should be considered as you write your assessment and plan.  For each problem, what will ideally follow as your assessment is a differential diagnosis for the problem (when appropriate), a statement demonstrating understanding of underlying pathophysiology, and a diagnostic and management plan.

 

Do not use systems (e.g., respiratory, cardiac) as the headers for discussion in your A/P, regardless of what your resident may tell you.  The “risks” of using this approach are that one problem may involve multiple systems (e.g., chest pain), and patients may have multiple problems with a single system (e.g., COPD, pneumonia, lung nodule).  A problem-based approach is generally much more effective and appropriate.

 

In some cases, the problem will be a symptom (abdominal pain);  in other cases, when a diagnosis is established by the data you have already collected, it will be a diagnosis (pancreatitis).  For example, the headers for your discussion in the A/P would be:

 

Correct

Incorrect

Chest pain

Cardiac

Pneumonia

Infectious Diseases

Lung Nodule

Oncologic

 

The Oral Presentation

You will hopefully be doing presentations regularly over the course of the clerkship.  For example, you will usually present your patient to your attending and the rest of the team the morning after admission.  This is an essential means of communicating information about patients.  Presentations often make students anxious.  Remember, “Practice makes perfect.”

 

The degree of thoroughness, the length of the presentation, and the content that you include will depend upon the audience to whom you are presenting.  Generally, HPI makes up 30 to 50 percent of the total presentation and is chronological, attentive to detail, and inclusive of pertinent positives and negatives.  In the past medical history, major ongoing chronic medical problems should be summarized succinctly.  Medications and allergies are always presented.  The social history, family history, and review of systems can usually be compressed.  If the information is key, it should probably be in HPI.  Your exam should be orderly and include all the pertinent positives and negatives.  Labs should be presented in an edited fashion (i.e., only abnormal values or normal values that are crucial to the diagnosis or excluding diagnoses).

 

Your assessment should include a brief discussion of the major problem(s), differential diagnosis of that problem, which diagnosis is most likely and why (using the data you have just presented), and the initial diagnostic and therapeutic strategy.  If you have done additional reading or research, present that information concisely afterwards.

 

  • Ask your resident or attending if you are uncertain about how much information to give.
  • Practice!  You may want to rehearse your presentation in advance.
  • “Tell the story” with minimal reference to notes.  Do not read off a photocopy of your H&P.  Have reference materials available if necessary.
  • Strive for five minutes; most listeners will be unable to attend for more than 10 minutes.
  • Answer questions to the best of your ability and pick up right where you left off.  It is good if people ask you questions.  If no one asks questions, you talked too long.
  • Do not improvise information if you are not sure.  If you do not know the answer to something that you are asked, it is OK to say you do not know.
  • Remember that the listener is creating, prioritizing, and re-prioritizing his or her own differential diagnosis based on what you say.
  • Remember that style counts!  Your presentation should be tightly organized, smooth, persuasive, and confident.

 

SOAP Notes

This is a format for clinic and daily notes. They allow other physicians to see how a patient's status has progressed and under what treatment. It is of great importance that you include in your assessment and plan both the treatment and the thought process behind each therapy. This will help those who cross-cover the patient at night and any consultant services. SOAP notes should be clear, complete and concise. The length will vary greatly among the services. Expect your longest notes to come from medicine and your shortest notes to be from OB/Gyn. See example below.

Events overnight: transferred OR, cardiac cath, etc.

  • S ubjective: Chief complaint and other pertinent history. Events overnight. "Mr. Jones reports feeling much better today. Denies SOB, chest pain, fever and chills. New productive cough. Eating well. Otherwise without complaint."
  • O bjective: Vital Signs usually include ranges (you should repeat the vital signs yourself if possible); PE: Includes the major systems (chest, CV, abdomen) plus involved areas; Labs; Cultures; X-rays
  • A ssessment: 1) S/P possible MI, presently stable without chest pain. 2) New cough.
  • P lan: 1) Check cardiac enzymes, taper nitropaste and arrange cardiac rehabilitation. 2) Follow temp, get new chest x-ray and obtain sputum.

Hint: for patients with more complicated presentations, it promotes clearer thinking to list the assessment/plan by problem:

Events overnight: transferred OR, cardiac cath, etc.

  • S ubjective: Chief complaint and other pertinent history. Events overnight. "Mr. Jones reports feeling much better today. Denies SOB, chest pain, fever and chills. New productive cough. Eating well. Otherwise without complaint."
  • O bjective: Vital Signs usually include ranges (you should repeat the vital signs yourself if possible); PE: Includes the major systems (chest, CV, abdomen) plus involved areas; Labs; Cultures; X-rays
  • Assessment/Plan
  • 1. Possible MI
    Presently stable without chest pain.
    Plan: Check enzymes, taper NTP, call rehab today.

  • 2. New cough
    Pt. with productive cough, but no fevers or chills.
    Plan: will follow temp curve, get Cx-ray and obtain sputum if cough persists.