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University of Washington

Chronic Care Clerkship

http://chroniccare.rehab.washington.edu/resources/documents/instructions.asp


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:

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 tejewell@u.washington.edu. 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:

  1. 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.

  2. 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.

Evaluation

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:

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.

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.

Patient and Family View of Chronic Illness: Information gained from interview of patient and family and/or significant others.

Discussion and Personal Reactions:


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