{"id":128093,"date":"2021-12-20T00:00:00","date_gmt":"2021-12-20T00:00:00","guid":{"rendered":"https:\/\/nursingstudybay.com\/2021\/12\/20\/criteria-for-evaluating-write-ups\/"},"modified":"2021-12-20T00:00:00","modified_gmt":"2021-12-20T00:00:00","slug":"criteria-for-evaluating-write-ups","status":"publish","type":"post","link":"https:\/\/www.studyproessays.com\/help\/criteria-for-evaluating-write-ups\/","title":{"rendered":"CRITERIA FOR EVALUATING WRITE-UPS"},"content":{"rendered":"

15
\nCRITERIA FOR EVALUATING WRITE-UPS
\nFeedback will consist of narrative comments, corrections, and suggestions and an overall rating
\nas described below: Preceptors will attend to the following criteria in evaluating the quality of
\nwrite-ups:
\na. Punctuality
\nb. Adherence to specified format with correct organization of data.
\nc. Write-up is neat, legible, and with few spelling errors..
\nd. Write-up accurately reflects what the patient reported during the interview.
\ne. Thoroughness (this will be evaluated in light of the amount of information provided in
\nthe interview e.g. it is expected that much information will not be covered by the
\ninterview).
\nf. Correct use of medical and psychiatric terminology
\ng. Conciseness, i.e. write-up is not long-winded, rambling, or filled with extraneous detail.
\nPlease edit your work before turning it in.
\nNOTE: Your ability to arrive at the correct diagnosis is not the major criterion for
\nAssessment. We are trying to help you learn to take, and then report, an
\naccurate and thorough psychiatric history and Assessment. You will learn
\ndiagnostics more fully in your clinical clerkship.
\nRating Scale
\nOutstanding: Adheres to specified format within correct organization of data; neat with no
\ngrammar or spelling errors; accurate reflection of patient report; thorough, but concise; correct
\nuse of medical\/psychiatric terms, AND PUNCTUAL.
\nExcellent: Adheres to specified format with minor errors in organization; no grammar or
\nspelling errors; generally reflects patient report; generally thorough (left out a few minor
\npoints) OR a bit rambling with some unnecessary detail; correct use of medical\/psychiatric
\nterms, AND PUNCTUAL.
\nGood: Some errors in adhering to format or organization, and\/or some grammar\/spelling
\nerrors; missing a few major points or rambling with unnecessary details; some errors in
\nmedical\/psychiatric terms AND PUNCTUAL.
\nFair: Some problems adhering to format; major errors in organization of data; grammar or
\nspelling errors; incomplete, missing some major points; some incorrect use of terms and\/or
\nhanded in LATE.
\nUnsatisfactory: Does not adhere to specified format or data poorly organized; some
\ngrammar\/spelling errors; poor reflection of patient report; incomplete; some incorrect use of
\nterms, and\/or LATE.
\n16
\nFORMAT FOR WRITE-UPS
\n\u2022 See the attached sample annotated write-up.
\n\u2022 Leave at least 1 inch margins on top, bottom, right and left to allow space for
\nwritten comments by preceptors.
\n\u2022 At the top of the page, put your name, your preceptors’ names, date of interview
\n(DOI), date the write-up is turned in, and the number of the write-up (the practice
\nwrite-up is write-up #1.)
\n\u2022 Type or handwrite neatly.
\n– single space within paragraphs
\n– double space between paragraphs
\n– triple space between sections
\n\u2022 Do not use the name of the patient in the write-ups. Use a letter instead (Mr. A or
\nMs. B., etc.)
\n\u2022 Organize the write-up into discrete sections with the following labels:
\n– Chief Complaint (Identifying Data & Presenting Problem)
\n– Source and Reliability
\n– HPI (History of Present Illness)
\n– Past Psychiatric Hx (Psychiatric History)
\n– Family Hx (Family History)
\n– Personal\/Social Hx (Personal History)
\n– Medical Hx (Medical History including allergies & current medications)
\n– MSE (Mental Status Exam) [See Sample for organization]
\n– Summary (Summary of Clinical Data)
\n– Principal Dx (Principal Diagnosis)
\n\u2022 Staple all pages in the upper left hand corner.
\n17
\nANNOTATED SAMPLE OF A WRITE-UP OF A PSYCHIATRIC Assessment
\n(The case is entirely fictional)
\nThis write-up is very detailed for illustration. The level of detail is more than you can extract
\nfrom an average patient in less than an hour, but it should give you an idea of what data are
\nuseful, as well as how to organize your own write-up. For example, it also reflects what might
\nbe typically obtained from patients or their charts, given more time. Ideally, you would want to
\nknow many specific details about treatment, but often the patient cannot recall them extensively,
\nor chart data are missing.
\nJoe Student
\nDrs. Pre and Ceptor
\nDOI: 3\/6\/94
\nDate: 3\/13\/94
\nWrite-up: #1
\nCC: This is the 1st PWC and 3rd psychiatric hospital1 admission for this 31 year old, married, white,
\nJewish female, currently employed as a lawyer, living with her husband and two children2, with
\nthe chief complaint of “I tried to kill myself yesterday.”3
\nSOURCE OF INFORMATION: Patient, judged to be reliable.4
\nHPI: Ms. A. was entirely well5 until five weeks prior to admission6 when she noted the onset of
\ndepressed and sad mood, and increasing irritability with her husband and children. At first, the
\ndepressed mood appeared to be confined to the early morning hours, but within several days
\nbegan to persist around the clock with the worst symptoms in the morning.7 She then had
\ndiminished appetite8 and reports a 4 lb weight loss over the next 4 weeks.9 She developed daily
\ncrying spells and began to feel hopeless, helpless, and ruminated that she was a burden.10 She
\nreports her husband then became concerned because she seemed less attentive to their 3 year old
\nson and 8 month old daughter and became socially withdrawn.11 She denied any change in
\nsexual functioning, fatigability, or poor memory.12 Approximately one week later13 she noted
\ntrouble concentrating on legal briefs at work, began to make errors, and had stopped returning
\ncalls of clients.14 She lost interest in painting and stopped reading the newspaper.15
\nAt around this time Ms. A reports she developed a persistent, severe, diffuse, throbbing
\nheadache each morning16 that usually responded completely to aspirin after several hours.17 She
\nalso reported feeling dizzy, weak, and with little energy. She had trouble falling asleep, had
\nrestless nights, and then often awoke at 5 a.m, unable to return to sleep.18 Because of her
\ninsomnia, she consulted with Dr. Highfee, a private psychiatrist, who was recommended by a
\nneighbor, on February 4th.19 She reported he said she was depressed20 and prescribed
\nNortriptyline 50 mg p.o.q.d. for two days to be increased to 75 mg p.o.q.d.21 Ms. A. says she
\ntook the medication as prescribed22 and saw Dr. Highfee a week later on Feb. 11th for a blood
\nlevel.23 She says she did not feel better,24 but developed blurry vision, dry mouth, and some
\ndizziness when standing.25 She then discontinued the medication26 without telling her husband
\nor Dr. Highfee.27
\n18
\nTwo weeks prior to admission the patient began calling in sick and missed two or three days
\nof work. She began to believe that people at work were plotting against her.28 On the night
\nof Feb. 15th after an argument over child care responsibility, she threw a vase at her
\nhusband, striking him on the arm. He was not injured.29 There had been no prior history of
\nviolence or assaultivness.30 The following morning the patient accused her husband of being
\nSatan and barricaded herself for two hours in the bedroom. Her husband telephoned Dr.
\nHighfee, but the patient refused to reschedule missed appointments.31
\nTwo days prior to admission the patient received a phone call telling her she had been
\nplaced on probation at work because of her absences.32 She became profoundly depressed33
\non hearing this news and began to wish she were dead, but did not make active plans for
\nsuicide.
\nOn the morning of admission34 the patient did not go to work. Alone in her house with her
\nchildren, after her husband had left for work in the morning, she locked herself in the
\nbathroom and swallowed all remaining (approximately twenty) 50 mg. tablets of
\nnortriptyline.35 She stated she wanted to die at the time, was desperately hopeless about her
\nfuture, and felt she was inadequate as a mother.36 Her husband tried to reach her by phone
\nin the afternoon several times, but was unsuccessful. At 5 p.m. the husband returned home
\nand called out to the patient and found the bathroom door locked.37 After breaking down the
\ndoor, he found her lying on the floor, unresponsive, with shallow respiration.38 He called an
\nambulance and then telephoned Dr. Highfee who agreed to meet the patient and the husband
\nat the NYH ER.39 Upon arrival in the ER, the patient was groggy, but arousable.40 After
\nmedical clearance, she was admitted to PWC 5.
\nOther recent stressors include the death of her maternal grandmother (5 months ago), the
\nresignation of her babysitter (1 month ago), and increasing work responsibilities.41
\nMs. A denied any manic symptoms, hallucinations, panic attacks, phobias, obsessions, or
\ncompulsions.42 Except for the symptoms above, she denied any change in her health. She
\nalso denied head trauma, seizures, loss of consciousness, or other focal neurological
\nsymptoms.43
\nShe reports drinking one glass of wine on weekends, but denied a recent change in drinking
\npattern.44 She smokes marijuana on average once or twice a month, but denies using
\ncocaine, opiates, sedatives or other drugs.45
\nPAST PSYCHIATRIC Hx:46
\n1980 Depressed after father died, counselling in college for several weeks.47
\n1988 Depressed for several weeks, with difficulty sleeping, diminished appetite,
\nbegan psychotherapy once a week for 6 months (Dr. Gutshrink); treated with
\nnortriptyline 75 mg q.d., alprazolam 1 mg p.o.q.d. with good response.48
\n1989 Suicide attempt after breakup with boyfriend (overdose with Xanax),
\nhospitalized for one week at Babbling Brook Hospital, signed out against
\nmedical advice. No further treatment.49
\n1991 Postpartum depression for 3 months; hospitalized for 1 month, treated with
\ndesipramine dose for several months with good response.50
\n19
\nFAMILY Hx:51
\nPERSONAL\/SOCIAL Hx:53
\nThe patient is the middle child of 5 children born to a middle class reform Jewish family in
\nGreat Neck, Long Island.54 She had normal developmental milestones55 Her father, whom
\nshe describes as aloof and cold, was a high school social studies teacher. Her mother, whom
\nshe describes as a “domineering worrywart” is a retired high school English teacher.56 She
\nattended a local public grammar school and achieved average grades. She went on to a
\nprivate suburban highschool, excelled in most subjects, and was a star violinist in the school
\nband.57 In her junior year of high school in 1980, her father died unexpectedly of a heart
\nattack.58 Her mother married a real estate broker a year later and moved with her younger
\ntwin brothers to Orlando, Florida.59 (Her mother with whom the patient has little contact,
\nsubsequently divorced in 1990 and continues to live in Florida).
\nThe patient attended Princeton, graduating with honors in history. She went on to Harvard
\nLaw School, where in her 1st year she was arrested but never convicted for vandalizing a
\nuniversity building as part of protest over the University’s divestiture of stock in companies
\ndealing with South Africa.60 She graduated near the top of her class, moved to New York,
\nand accepted a job as an associate at a prestigious corporate law firm, where she has worked
\never since, advancing rapidly.61
\nThe patient reports dating intermittently in high school and college.62 She says she had a
\n“fling” with a law professor, who was married at the time. After moving to New York she
\nhad a one year live-in relationship with a heavy-metal musician. She reports he abused
\ncocaine and alcohol and frequently beat her during arguments over sex. She broke up after
\nshe learned he had been dating other women on the side.63 She then dated a lawyer
\nemployed at a competing firm, whom she ultimately married in 1991. Shortly before her
\nwedding, her older sister committed suicide, and her younger brother, with whom she was
\nclose, was diagnosed with Crohn’s disease.64 She lives with her husband, 2 children and a
\nlive-in babysitter in an expensive co-op apartment on the Upper East Side.65
\nMEDICAL Hx:66 In general, good health67
\n1979, appendectomy68
\n1982, motor vehicle accident69 (passenger)70: hospitalized for three
\ndays with back sprain, lacerations. No loss of
\nconsciousness,71 physical rehabilitation for 6 months
\n1986-1990, severe headaches72 of unknown etiology CT Scan
\nnegative, treated with cafergot and “pain killers”73
\nintermittently
\n1987, HIV-negative (reported)74
\nAllergies: penicillin (rash)75
\nCurrent medication: none76
\n20
\n(Note: Current medication in an admission interview reflects
\nmedications patient is taking immediately prior to admission. You
\nmight specify for patients in the hospital what their regimen is. In
\nthis case she is taking Desipramine 150 mg p.o.q.h.s. (q.h.s. =
\nbedtime) and Haloperidol 2 mg p.o. q.h.s.)
\nMSE:
\nAppearance: Thin, pale white female with blond hair, appearing her stated age of 31, neatly
\ngroomed, casually attired in a blouse and plaid skirt. Good eye contact. No
\nabnormal movements. Pleasant and cooperative.
\nSpeech: spontaneous, slightly slowed, normal rhythm, soft tone
\nAffect: sad, constricted
\nMood: depressed, “I still feel down”
\nThought process: goal directed, logical, linear
\nThought content: Continues to report feeling sad, hopeless, preoccupied with losing her job and
\ninadequacy as a mother. Now regrets making suicide attempt labelling it
\n“foolish” and “upsetting to her family”. Denies current suicidal ideation,
\nintent, or plan. No homicidal ideation, intent or plan. No hallucinations,
\ndelusions, obsessions.
\nHIF: alert, oriented X 3
\nConcentration: fair, digit span 4->, 3<- with mistakes
\nMemory: immediate: good (immediate recall of 3 objects)
\nrecent: 3\/3 objects in five minutes
\nremote: Presidents BC->GB->RR->JC->GF->RN
\nCalculations: $1.50 = 6 Qtrs $1.35 = 37 nickels
\nserial 7’s 100->93->86->79->72->64->57
\nAbstracting ability: intact
\nsimilarities: apple\/orange: “fruit”
\ntable\/chair: “furniture”
\nbird\/plane: “fly”
\nproverbs: book by cover: “don’t judge people on the outside only”
\nJudgment: fair
\nInsight: good, knows she is depressed and wants help, no longer believes
\npeople are plotting against her or that her husband is Satan.
\nSUMMARY:78 This 31 y.o. married, white, female lawyer, mother of 279, has a history of
\nseveral depressive80 episodes81 responsive to antidepressant medication.82
\n21
\nShe has a strong family history for affective disorders.83 She now presents
\nfollowing a serious suicide attempt after five weeks of depressed mood,
\nneurovegetative symptoms, diminished concentration, helplessness,
\nhopelessness, and paranoid delusions.84
\nPRINCIPAL Dx: Major Depression, recurrent, severe, with Psychotic Features85 (resolving).86
\nFOOTNOTES
\nChief Complaint
\n1. This means the patient has had a total of 3 psychiatric admissions in her life, 2 of which
\nwere at a hospital other than PWC. If the patient does not know how many admissions she
\nhas had you might begin with “This is the 1st PWC admission and one of several psychiatric
\nadmissions….”.
\n2. At a minimum you should include age, race, sex, and marital status. You may wish to add
\nhere the religion or ethnicity of the patient, her employment status, occupation, and current
\nliving arrangement.
\n3. The CC should be written in quotes and is usually the patient’s verbatim answer to the
\ninterviewer’s question, “What brought you to the hospital” It might be a psychotic response
\ne.g. “I am the incarnation of Vishnu” etc. Some writers will substitute the phrase “admitted
\nfor a suicide attempt” but verbatim answers are generally preferable.
\nSource of Information
\n4. Describe the source(s) of information e.g. patient, chart, family, treating physician and
\nreliability of the source. In this course, the source will usually be the patient exclusively.
\nHistory of Present Illness
\n5. It is important to comment on the baseline functioning of the patient prior to the onset of the
\npresent “episode” of illness. For patients who are chronically ill you might say the patient
\nhas a long psychiatric history and was in her usual state of health until five weeks…..
\n6. The onset of the present illness should be stated in a time frame and is usually when the
\npatient notes the beginning of symptoms. You will need to use your own judgment as to
\nwhen the illness began. For example, this patient could have initially talked about her
\nsuicide attempt the day before admission. Only later in your interview would you realize
\nthat depressive symptoms had begun 5 weeks earlier. For those with chronic symptoms you
\nmay choose the onset of an exacerbation of symptoms as the time frame e.g. the patient was
\nin her usual state of poor mental health until five weeks prior to admission when she noticed
\nworsening auditory hallucinations.
\n7. It is important to show the progression or worsening of symptoms.
\n8. One could also substitute psychiatric terms here e.g. she developed anorexia.
\n9. Weight loss, an important medical and psychiatric symptom, should be quantitated in
\namount and over what period of time. If the patient was deliberately dieting, it should be
\nnoted.
\n10. It is useful to insert other symptoms that complete the clinical picture.
\n22
\n11. Comment on how the illness affects her social role and functioning.
\n12. One might choose to list negatives pertinent to the clinical picture here. Pertinent negatives
\nof a more general nature can be listed at the end to avoid unduly disrupting the narrative
\nflow.
\n13. Provide some sense of time sequence.
\n14. Describe effects on occupational role.
\n15. Describe effects on daily activities and interests e.g. this shows the patient had developed
\nanhedonia.
\n16. Do not neglect mention of medical symptoms (i.e. this patient could have a brain tumor)
\nwhich may be part of the psychiatric syndrome or even causative .
\n17. Describe as you would for any medical symptom – its duration, location, quality, severity,
\ntime of onset. Note also what the patient did (i.e. she took aspirin) and what the response
\nwas.
\n18. Another way to phrase this sentence is She developed pan-insomnia and early morning
\nawakening.
\n19. Report why (insomnia), with whom (Dr. Highfee) the location, level, and background of
\ntraining (a private psychiatrist) of physicians or health professionals consulted.
\n20. Notice phrasing here. This has legal ramifications. The patient reported Dr. Highfee said
\nshe was depressed. This is preferable to Dr. Highfee diagnosed depression unless you have
\npersonally spoken to Dr. Highfee to confirm his diagnosis.
\n21. p.o. is by mouth; q.d. is once a day. (b.i.d. is twice a day, t.i.d. is three times a day, q.i.d. is
\nfour times a day). It is best to state the drug’s name if the patient can remember it. In some
\ncases you may have to say he prescribed a drug. State the prescribe regimen if known.
\n22. Describe how the patient reports actually taking the medication. What is prescribed and
\nwhat is actually taken are not always the same.
\n23. If you know an actual blood level, report it, as it is useful information. This is true of
\nany test e.g. chest x-ray, CT scan etc. Remember to report as you know the facts e.g. Dr.
\nHighfee reported the blood level to be 0.70 mg\/ml or the chart indicated the blood level was
\n0.70mg\/ml or Dr. Highfee said the blood level was “therapeutic”.
\n24. Indicate the response. Dr. Highfee, had he been called by you, might have said she did
\nrespond.
\n25. Indicate side effects. They are useful to know for your own treatment plan.
\n26. Indicate her compliance.
\n27. This is useful because it suggests the patient may be secretive or unreliable or
\nuncooperative.
\n28. Mention additional symptoms that evolve.
\n29. Always mention a history of violence and the outcome in a psychiatric history.
\n23
\n30. This is useful because it tells you this episode was unusual by history and also mentions the
\npast history of violence.
\n31. This answers why the patient was not further involved with Dr. Highfee.
\n32. Describe recent stressors or events that may serve as precipitants for additional behaviors or
\nsymptoms. Do not infer causality. That is, do not say she was placed on probation and
\nbecause of this became suicidal.
\n33. This describes the patient’s reaction to the stressor and, in effect, justifies your notion that
\nprobation was a stressor. Remember what would seem stressful to you is not always to the
\npatient, and vice versa.
\n34. It is useful to describe the events right before admission in greater detail.
\n35. Any suicide attempts (also violence or bizarre behaviour) should be described in detail.
\nNote this sentence conveys the steps the patient took to avoid intervention (e.g. waited for
\nhusband to go to work, locked herself in her bathroom, etc.). You should report what the
\npatient took, the amount, and whether all pills were taken (i.e. some patients take only a few
\nand leave the rest either because of ambivalence about dying, or naivete about lethal
\ndosages).
\n36. Report what was going through the patient’s mind at the time and what her intent and
\nexpectations were.
\n37. Describe whether the patient tried to obtain help herself after attempting suicide, or more
\nominously in this case made (or was unable to make) no attempt to seek help. You might
\nalso comment here, if not in the past psychiatric history section, whether the patient had
\nmade previous suicide attempts in her life.
\n38. Describe the patient’s response or clinical state. Note: the husband found her lying on the
\nfloor is more accurate than she had fallen to the floor.
\n39. Always describe how the patient got to the hospital. In many cases the patient comes
\nvoluntarily at the urging of a psychiatrist. Others may just decide on their own to go.
\nOthers are “dragged” in by family.
\n40. Describe the patient’s condition on arrival if this is relevant.
\n41. List other recent stressors (both chronic and acute) which may be relevant to the clinical
\npresentation.
\nIn the remaining section it is important to add pertinent negatives.
\n42. List pertinent negatives of other psychiatric symptoms. This is most important in
\nformulating a differential diagnosis. It is unclear until this point, for example, whether this
\npatient’s depression is unipolar or bipolar or whether she has additional psychiatric
\ndisorders. Remember a patient can have more than one disorder. This list of negatives also
\nindicates to the reader that you asked about these symptoms rather than overlooked them.
\n43. List pertinent medical negatives. This should also include negative neurologic symptoms
\ne.g. head trauma, seizures, etc.
\n24
\n44. Always report the usual pattern of alcohol consumption and how that pattern has changed.
\nTry to be as specific as possible. For alcoholic patients, state when the last drink was. This
\nis important diagnostically and therapeutically. You may need to place the patient on
\nprecautions for withdrawal. In addition, many patients with mental illness have comorbid
\n(i.e. co-occurring) alcohol or substance abuse.
\n45. As for alcohol, describe pattern of use of psychoactive drugs. Remember “legal” drugs, e.g.
\nbenzodiazepines, can be abused, and can also be obtained illegally.
\nPsychiatric History
\n46. List the history chronologically, documenting as best you can diagnosis, clinical
\npresentation, type and duration of treatment, and response.
\n47. Include counseling, psychotherapy. If possible, describe type of therapy, e.g. cognitive
\ntherapy, behavioral desensitization, “herbal” therapy, etc. If possible, indicate reason for
\nseeking therapy.
\n48. List medication, dosage regimen, if possible, with response. Provide name of treating
\ndoctor. This will facilitate your contacting this doctor for additional information.
\n49. Always list suicide attempts or non-suicidal self-destructive acts. If possible, provide details
\nregarding circumstances and method of attempt, degree of injury sustained, and treatment.
\nList name of hospital to facilitate obtaining additional charts.
\n50. Document all hospitalizations with their duration and treatment modalities. Be sure to
\ninquire about electroconvulsive therapy (ECT).
\nFamily History
\n51. Interpretation of the genogram: The patient’s father (a high school teacher), died in 1980 at
\nage 53 of a heart attack. The patient’s mother, age 63, is a retired schoolteacher. She
\nmarried a real estate broker in 1981 but then divorced in 1990. The patient had four
\nsiblings. Her sister who had a history of depression committed suicide in 1990 at age 33.
\nHer older brother, age 39, has “manic-depressive” illness and alcoholism. The patient has 2
\nyounger brothers, age 25, who are identical twins, one of whom has Crohn’s disease. The
\npatient is married to a lawyer, age 31. They have an 8-month-old daughter and 3-year-old
\nson.
\n52. Indicate other family members who may not be described in the genogram who have had
\nmental illnesses or made suicide attempts (or who have important genetic diseases e.g.
\nHuntington’s disease, etc.). If possible, describe the diagnosis, treatment response, age when
\ndiagnosed (this is not often known by the patient).
\nSocial History
\n53. Note this is probably more extensive than you may obtain in a single interview.
\n54. General description of family structure, social class, culture, location.
\n55. Note abnormalities, if any, in development, e.g. delays in speech, walking, etc.
\n25
\n56. Describe parents’ occupations and how patient perceives relationships with them.
\n57. Describe type of school, academic performance, special interests (indicate if patient failed,
\nwas disciplined, or truant, or dropped out).
\n58. Indicate major family events.
\n59. Indicate moves or family separations.
\n60. Mention trouble with the law, legal difficulties, arrests, if any.
\n61. Summarize work history, including promotions, reasons for leaving or termination, job
\nsatisfaction.
\n62. Describe interpersonal relationships with others from childhood. Indicate if patient was
\nsocially withdrawn, promiscuous, etc.
\n63. Describe reasons for break-up.
\n64. Although some of this data is mentioned in the family history, it is repeated here only
\nbecause it had a particular emotional impact on the patient. Note that the patient’s oldest
\nbrother has manic-depressive illness, which is not described here because it may not have
\nhad as much of an impact, and it is appropriately mentioned in the family history.
\n65. Describe current living situation. Also, it would be important to mention all children,
\nincluding those out of wedlock, if any, and abortions.
\nMedical History
\n66. Can be reported as a chronological list.
\n67. Summary statements about overall state of health can be useful.
\n68. List major surgery (document complications, if any).
\n69. Report significant accidents and their treatments.
\n70. Passenger status is mentioned because some accidents are disguised forms of suicidal
\nbehavior.
\n71. Comment on head trauma.
\n72. Comment on neurological symptoms.
\n73. If doses and duration are known, report them. Some patients can only remember receiving a
\n“pill” or a “pain killer”. You might also mention name of family doctor.
\n74. Report major tests.
\n75. Describe the type of allergy e.g. rash, anaphylaxis, urticaria, if possible, Some patients
\nimproperly consider a side-effect to be an allergy.
\n76. List current dosage regimen, if applicable.
\n26
\nMental Status Exam
\n77. This will not be annotated here. Consult Chapter 1 and 2 of the text.
\nSummary
\n78. Provide one or two sentences that summarize the main epidemiologic risk factors, historical
\ndata, including treatment, response, current clinical presentation and data on longitudinal
\ncourse that allow you to arrive at your diagnostic impression.
\n79. This reiteration of demographic data is important. Depression is more common among
\nyoung females. The mention of married lawyer and mother of 2 suggests relatively high
\nfunctioning which would be inconsistent with other diagnoses e.g. schizophrenia.
\n80. The previous mental illness e.g. depression makes it more likely that the current illness is
\ndepression.
\n81. Episode connotes a brief period of illness and gives information about course. For a
\nschizophrenic you might have said with a long deteriorating course.
\n82. Although it is not foolproof, treatment response is a reasonable “post hoc” confirmation of a
\ndiagnosis.
\n83. Family history is a strong epidemiologic risk factor for the type of mental illness.
\n84. Summarize important symptoms at the time of presentation.
\nPrincipal Diagnosis
\n85. Write what you believe is the principal diagnosis. The diagnosis is usually specified by
\nDSM-5 criteria, which often distinguishes between single episodes versus recurrent, level of
\nseverity, and presence or absence of psychotic features.
\nNote: If you just read the MSE only, you would note that the patient was not psychotic at the time
\nshe was interviewed. Presumably she had been treated for her psychotic features. This
\nunderscores the importance of not relying on cross-sectional data, but rather diagnosing
\nbased on disease course.
\n86. Her illness is improving.