Writing H&Ps

Internal Medicine is the branch of medicine that deals with the diagnosis and treatment of diseases of the internal organ systems. The internist's purview is all adult illness that is non-surgical, ranging from primary care and health promotion issues to the management of complex, multisystem disease. Perhaps the skill that most defines an internist is the ability to synthesize and organize the often voluminous amount of medical data that the modern health care system generates. An internist is then able to document and present this refined information in a complete, concise and coherent fashion.

It is one of the major goals of the UNC Medicine Inpatient Clerkship that all students will become adept at gathering, synthesizing and documenting the information that is important for the care of their patients. As a tool to teach this critical aspect of medicine, students are required to complete and submit to the clerkship office five (5) detailed H&Ps. These H&Ps should include a problem list, differential diagnoses and a patient-oriented assessment that includes a diagnostic and therapeutic plan for each of the patient's active problems. These H&Ps must represent a medical history and physical examination actually performed by the medical student. Although at times a student might "tag along" and observe/participate in the examination done by the resident team, this experience does not match the learning experience inherent in performing the information gathering personally. While students are only required to turn in five H&Ps, all students will write many more than the required number. All H&Ps should be given to the ward attending for evaluation and constructive comments. The ward attending must sign each H&P. This is to ensure that an attending has seen (and ideally read and provided constructive criticism on) all the H&Ps. Students should then turn in a copy of five signed write-ups to the clerkship office. The H&Ps are due in Carol Carden's office by the last day of the clerkship. Students not completing this assignment will have their grade reduced one grade level. This is a PASS/FAIL component of the clerkship.

As part of your clerkship grade, one of the H&Ps (selected by you) will be graded by the clerkship director using specific evaluation criteria. This H&P must be submitted to Carol Carden's office by the last day of the clerkship. Please write "For formal evaluation" on the top of the first page and attach the "Evaluation of Student H&P" form to the front. Be sure to put your name on the form. This H&P does count towards the five required H&Ps (i.e. you only need to turn in four other H&Ps).

****Please remember HIPAA and respect patient confidentiality.   Make sure that all individually identifiable health information (e.g., full names, medical record numbers) is blacked out prior to submitting write-ups to Carol Carden's office.****