Patient Case Write-up & Presentation
Patient Case Write-up Instructions
all Chronic Care students
You will complete a major comprehensive write-up of a patient and family, including medical history, psycho-social history, assessment of functioning, development of patient/family centered goals and an environmental assessment. In consultation with your preceptor, you will choose a patient and family to be the subject of this case write-up. In most instances, you will make at least one visit to the patient's home or the non-hospital facility where the patient is residing.
The most important source of information for this write-up will be the patient and “family”. In order to complete this assignment, you will also need to:
- Review the patient's medical record.
- Interview members of the patient's family or others who have had responsibility for day-to-day care of the patient.
- Interview a variety of health care workers who have had responsibility for care of the patient. These could include, but are not limited to, physicians, nurses, psychologists, physical therapists, occupational therapists, social workers, and case managers.
- Review insurance and other financial information relevant to the care of the patient.
The write-up will be recorded on the Patient Case Write-up Form. Please follow the directions on the form, save a copy for yourself, and forward a copy to the Clerkship Coordinator at firstname.lastname@example.org. The length of the write-up will vary from student to student, but expect to commit a significant amount of time to carefully responding to each question. Additional write-up questions can be found here.
Additional write-up resources can be found in the Resources, Handouts & Readings section of this website.
You should expect to commit at least one half day to a visit to the patient in his or her home or other residence. You will also need to spend additional time to complete interviews of family members, hospital based health care workers, and other individuals involved with the patient's case.
If you have no patient discharges that lend themselves to a home visit, you have two alternate options:
- You can assemble the family of a patient who is on your service and interview them at the hospital; you should be able to answer the write-up questions about the interface between the patient and his/her multiple environments, i.e. social, physical, environmental etc. by doing the detailed interview. You must indicate that you obtained this information from the family without visiting their home.
- You can negotiate through your attending to do a home visit with one of the visiting nurses. You will be interviewing a patient whom you have not previously met. However, other students have found this option was surprisingly rewarding.
The co-director for your specific discipline focus will evaluate your write-up on the basis of thoroughness in covering the issues included in the write-up questions, clarity and organization, recognition of community-based barriers and resources experienced by the patient, insight into the patient's perception of her/his circumstances and care given, and integration of course content into the approach to the patient included in the writeup
Things To Consider in Preparing Your Write-up Content Outline
While each of the following issues might not be appropriate to your case, you might consider the following while you are planning your response. A good write-up will take at least two drafts before it is ready to submit. The issues below may help you remember important topics to include.
Medical Context: Information collected from records of treatment in clinics or hospitals:
- Relevant history of chronic illnesses: nature, history of onset and course of disease related to functional abilities.
- Relevant history of treatment and hospitalization.
- Summaries of reports from other physicians and health care providers.
- Social support history, including friends, family, community, other services.
- Assessment of Activities of Daily Living skills, fall risk.
- Medication and treatment management plans including payment, organization and management outside of a facility.
- Prognosis for the patient. If the patient has advanced, life limiting illness, indicate if palliative care options were discussed.
Economic Context: Information about economic issues gained from review of insurance coverage, interviews with patients and case managers, etc and how these issues effected the medical care provided.
- Insurance coverage or other resources available.
- Limitations or conditions on expenditures.
- Resources needed for treatment and life expenses.
- Unmet needs.
Function in the Home or Facility Setting: Information and support needs from observations in the home or facility regarding pt/family roles, responsibilities, activities of daily living, mobility, safety and caregiver needs.
- Loss of important roles and responsibilities by the patient.
- Gain of important roles and responsibilities by the family caregiver.
- Gait and transfer ability.
- Demonstration of functional status in the home.
- Social support services used or needed.
- Medication management, including storage, organization, administration.
- Access to and use of durable medical equipment.
- Barriers to performing activities of daily life.
- Safety issues.
- Adequacy of caregivers.
Patient and Family View of Chronic Illness: Information gained from interview of patient and family and/or significant others.
- Values and goals.
- What values and goals are shared by pt/family?
- What values and goals differ among pt/family?
- View of quality of life.
- What views of quality of life are shared by the pt/family?
- What views of quality of life differ among pt/family?
- For those patients/families living with advanced, life limiting illness was a palliative care discussion conducted?
- If so what were the pt/family values and goals for medical care?
- If not, why not?
- If not what was the effect on the pt/family medical care and quality of life?
- View of unmet needs for treatment or services.
Discussion and Personal Reactions:
- Identification of patient's overall reaction to chronic illness and goals for treatment and management of illness.
- Gaps between patient goals and medical context caused by:
Role of the physician in providing medical care congruent with patient/family goals and values.
Barriers to appropriate care.
Significance of the case to your overall preparation as a physician.
- Medical team not soliciting patient/family values and goals.
- Patient/Family not accepting Medical Context.
- Medical team not integrating into medical care patient/family values and goals.
- Patient/family not integrating medical team's values and goals.
- “Unrealistic” patient/family expectations.
- “Unrealistic” medical team expectations.
- Problems with the physical environment.
- Lack of financial resources.
- Lack of social support.