The purpose of the Case Write-Up Assignment is to demonstrate your advanced prac

The purpose of the Case Write-Up Assignment is to demonstrate your advanced practice thinking and clinical decision-making skills. You will select a patient seen in your current clinical rotation and write up the visit, ensuring that any identifying patient factors are omitted.
To ensure that your write-ups are comprehensive and reflect your learning, start fresh and avoid copying and pasting from templates, examples, or other students’ work.
Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.
Subjective:
Chief complaint (CC): Patient reported that “I’ve had a cough and sore throat for 2 days”
History of Present Illness (HPI): important part of assessment, use important questions to ask (OLD CARTS or PQRST) which includes: Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Related symptoms, Treatments, and Significance. Includes details on current illness and symptoms.
Past Medical History: details on past and present illnesses, be careful not to blindly copy from prior clinical notes
Past Hospitalizations: past hospitalizations with reason for admit, duration of stay, and rough dates
Past Surgical History: past surgeries and rough dates when possible
Medications: list name, dose, frequency, and indication. Include PRN medications and how often they are taken.
Allergies: list medications and food allergies, specify type of reaction
Social History: includes several factors such as alcohol use, cigarette use, sexual history, work history, exercise, and immunizations.
Other pediatric considerations: includes information on home life, siblings, pets, daycare/school, extracurricular activities, and recent changes.
Family History: go back 2 generation – indicate if alive, deceased, or unknown. details on family members, their age, and illnesses/conditions.
Obstetrical History: relevant information on pregnancies when appropriate.
Review of Symptoms (ROS): should be extensive and include every system for comprehensive visits. For childbearing women, document LMP and contraceptive use on every visit. Do not include any objective data.
Objective:
Vital signs: include BMI on every visit
Physical examination(PE): This is head to toe detailed and thoroughly describe findings within ALL systems for comprehensive exam.
Laboratory data, diagnostic tests, imaging: include only available results at the time of the visit
Assessment:
List differential diagnoses and presumptive diagnosis, include appropriate ICD-10 codes for all diagnoses. Support diagnoses with evidence-based references.
Document ICD code diagnoses. Differential diagnosis list may be necessary.
Abnormalities found in ROS or physical exam need to be addressed.
Plan:
Include medications ordered, lab tests, teaching, referrals, and follow-up information. Organize information under each diagnosis.
Include patient education and health maintenance, such as cancer screenings.
Addendum:
Add additional note at the end of the write-up labeled “Addendum” if anything was missing from the encounter that should have been done or ordered.