15
CRITERIA FOR EVALUATING WRITE-UPS
Feedback will consist of narrative comments, corrections, and suggestions and an overall rating
as described below: Preceptors will attend to the following criteria in evaluating the quality of
write-ups:
a. Punctuality
b. Adherence to specified format with correct organization of data.
c. Write-up is neat, legible, and with few spelling errors..
d. Write-up accurately reflects what the patient reported during the interview.
e. Thoroughness (this will be evaluated in light of the amount of information provided in
the interview e.g. it is expected that much information will not be covered by the
interview).
f. Correct use of medical and psychiatric terminology
g. Conciseness, i.e. write-up is not long-winded, rambling, or filled with extraneous detail.
Please edit your work before turning it in.
NOTE: Your ability to arrive at the correct diagnosis is not the major criterion for
evaluation. We are trying to help you learn to take, and then report, an
accurate and thorough psychiatric history and evaluation. You will learn
diagnostics more fully in your clinical clerkship.
Rating Scale
Outstanding: Adheres to specified format within correct organization of data; neat with no
grammar or spelling errors; accurate reflection of patient report; thorough, but concise; correct
use of medical/psychiatric terms, AND PUNCTUAL.
Excellent: Adheres to specified format with minor errors in organization; no grammar or
spelling errors; generally reflects patient report; generally thorough (left out a few minor
points) OR a bit rambling with some unnecessary detail; correct use of medical/psychiatric
terms, AND PUNCTUAL.
Good: Some errors in adhering to format or organization, and/or some grammar/spelling
errors; missing a few major points or rambling with unnecessary details; some errors in
medical/psychiatric terms AND PUNCTUAL.
Fair: Some problems adhering to format; major errors in organization of data; grammar or
spelling errors; incomplete, missing some major points; some incorrect use of terms and/or
handed in LATE.
Unsatisfactory: Does not adhere to specified format or data poorly organized; some
grammar/spelling errors; poor reflection of patient report; incomplete; some incorrect use of
terms, and/or LATE.
16
FORMAT FOR WRITE-UPS
• See the attached sample annotated write-up.
• Leave at least 1 inch margins on top, bottom, right and left to allow space for
written comments by preceptors.
• At the top of the page, put your name, your preceptors’ names, date of interview
(DOI), date the write-up is turned in, and the number of the write-up (the practice
write-up is write-up #1.)
• Type or handwrite neatly.
– single space within paragraphs
– double space between paragraphs
– triple space between sections
• Do not use the name of the patient in the write-ups. Use a letter instead (Mr. A or
Ms. B., etc.)
• Organize the write-up into discrete sections with the following labels:
– Chief Complaint (Identifying Data & Presenting Problem)
– Source and Reliability
– HPI (History of Present Illness)
– Past Psychiatric Hx (Psychiatric History)
– Family Hx (Family History)
– Personal/Social Hx (Personal History)
– Medical Hx (Medical History including allergies & current medications)
– MSE (Mental Status Exam) [See Sample for organization]
– Summary (Summary of Clinical Data)
– Principal Dx (Principal Diagnosis)
• Staple all pages in the upper left hand corner.
17
ANNOTATED SAMPLE OF A WRITE-UP OF A PSYCHIATRIC EVALUATION
(The case is entirely fictional)
This write-up is very detailed for illustration. The level of detail is more than you can extract
from an average patient in less than an hour, but it should give you an idea of what data are
useful, as well as how to organize your own write-up. For example, it also reflects what might
be typically obtained from patients or their charts, given more time. Ideally, you would want to
know many specific details about treatment, but often the patient cannot recall them extensively,
or chart data are missing.
Joe Student
Drs. Pre and Ceptor
DOI: 3/6/94
Date: 3/13/94
Write-up: #1
CC: This is the 1st PWC and 3rd psychiatric hospital1 admission for this 31 year old, married, white,
Jewish female, currently employed as a lawyer, living with her husband and two children2, with
the chief complaint of “I tried to kill myself yesterday.”3
SOURCE OF INFORMATION: Patient, judged to be reliable.4
HPI: Ms. A. was entirely well5 until five weeks prior to admission6 when she noted the onset of
depressed and sad mood, and increasing irritability with her husband and children. At first, the
depressed mood appeared to be confined to the early morning hours, but within several days
began to persist around the clock with the worst symptoms in the morning.7 She then had
diminished appetite8 and reports a 4 lb weight loss over the next 4 weeks.9 She developed daily
crying spells and began to feel hopeless, helpless, and ruminated that she was a burden.10 She
reports her husband then became concerned because she seemed less attentive to their 3 year old
son and 8 month old daughter and became socially withdrawn.11 She denied any change in
sexual functioning, fatigability, or poor memory.12 Approximately one week later13 she noted
trouble concentrating on legal briefs at work, began to make errors, and had stopped returning
calls of clients.14 She lost interest in painting and stopped reading the newspaper.15
At around this time Ms. A reports she developed a persistent, severe, diffuse, throbbing
headache each morning16 that usually responded completely to aspirin after several hours.17 She
also reported feeling dizzy, weak, and with little energy. She had trouble falling asleep, had
restless nights, and then often awoke at 5 a.m, unable to return to sleep.18 Because of her
insomnia, she consulted with Dr. Highfee, a private psychiatrist, who was recommended by a
neighbor, on February 4th.19 She reported he said she was depressed20 and prescribed
Nortriptyline 50 mg p.o.q.d. for two days to be increased to 75 mg p.o.q.d.21 Ms. A. says she
took the medication as prescribed22 and saw Dr. Highfee a week later on Feb. 11th for a blood
level.23 She says she did not feel better,24 but developed blurry vision, dry mouth, and some
dizziness when standing.25 She then discontinued the medication26 without telling her husband
or Dr. Highfee.27
18
Two weeks prior to admission the patient began calling in sick and missed two or three days
of work. She began to believe that people at work were plotting against her.28 On the night
of Feb. 15th after an argument over child care responsibility, she threw a vase at her
husband, striking him on the arm. He was not injured.29 There had been no prior history of
violence or assaultivness.30 The following morning the patient accused her husband of being
Satan and barricaded herself for two hours in the bedroom. Her husband telephoned Dr.
Highfee, but the patient refused to reschedule missed appointments.31
Two days prior to admission the patient received a phone call telling her she had been
placed on probation at work because of her absences.32 She became profoundly depressed33
on hearing this news and began to wish she were dead, but did not make active plans for
suicide.
On the morning of admission34 the patient did not go to work. Alone in her house with her
children, after her husband had left for work in the morning, she locked herself in the
bathroom and swallowed all remaining (approximately twenty) 50 mg. tablets of
nortriptyline.35 She stated she wanted to die at the time, was desperately hopeless about her
future, and felt she was inadequate as a mother.36 Her husband tried to reach her by phone
in the afternoon several times, but was unsuccessful. At 5 p.m. the husband returned home
and called out to the patient and found the bathroom door locked.37 After breaking down the
door, he found her lying on the floor, unresponsive, with shallow respiration.38 He called an
ambulance and then telephoned Dr. Highfee who agreed to meet the patient and the husband
at the NYH ER.39 Upon arrival in the ER, the patient was groggy, but arousable.40 After
medical clearance, she was admitted to PWC 5.
Other recent stressors include the death of her maternal grandmother (5 months ago), the
resignation of her babysitter (1 month ago), and increasing work responsibilities.41
Ms. A denied any manic symptoms, hallucinations, panic attacks, phobias, obsessions, or
compulsions.42 Except for the symptoms above, she denied any change in her health. She
also denied head trauma, seizures, loss of consciousness, or other focal neurological
symptoms.43
She reports drinking one glass of wine on weekends, but denied a recent change in drinking
pattern.44 She smokes marijuana on average once or twice a month, but denies using
cocaine, opiates, sedatives or other drugs.45
PAST PSYCHIATRIC Hx:46
1980 Depressed after father died, counselling in college for several weeks.47
1988 Depressed for several weeks, with difficulty sleeping, diminished appetite,
began psychotherapy once a week for 6 months (Dr. Gutshrink); treated with
nortriptyline 75 mg q.d., alprazolam 1 mg p.o.q.d. with good response.48
1989 Suicide attempt after breakup with boyfriend (overdose with Xanax),
hospitalized for one week at Babbling Brook Hospital, signed out against
medical advice. No further treatment.49
1991 Postpartum depression for 3 months; hospitalized for 1 month, treated with
desipramine dose for several months with good response.50
19
FAMILY Hx:51
PERSONAL/SOCIAL Hx:53
The patient is the middle child of 5 children born to a middle class reform Jewish family in
Great Neck, Long Island.54 She had normal developmental milestones55 Her father, whom
she describes as aloof and cold, was a high school social studies teacher. Her mother, whom
she describes as a “domineering worrywart” is a retired high school English teacher.56 She
attended a local public grammar school and achieved average grades. She went on to a
private suburban highschool, excelled in most subjects, and was a star violinist in the school
band.57 In her junior year of high school in 1980, her father died unexpectedly of a heart
attack.58 Her mother married a real estate broker a year later and moved with her younger
twin brothers to Orlando, Florida.59 (Her mother with whom the patient has little contact,
subsequently divorced in 1990 and continues to live in Florida).
The patient attended Princeton, graduating with honors in history. She went on to Harvard
Law School, where in her 1st year she was arrested but never convicted for vandalizing a
university building as part of protest over the University’s divestiture of stock in companies
dealing with South Africa.60 She graduated near the top of her class, moved to New York,
and accepted a job as an associate at a prestigious corporate law firm, where she has worked
ever since, advancing rapidly.61
The patient reports dating intermittently in high school and college.62 She says she had a
“fling” with a law professor, who was married at the time. After moving to New York she
had a one year live-in relationship with a heavy-metal musician. She reports he abused
cocaine and alcohol and frequently beat her during arguments over sex. She broke up after
she learned he had been dating other women on the side.63 She then dated a lawyer
employed at a competing firm, whom she ultimately married in 1991. Shortly before her
wedding, her older sister committed suicide, and her younger brother, with whom she was
close, was diagnosed with Crohn’s disease.64 She lives with her husband, 2 children and a
live-in babysitter in an expensive co-op apartment on the Upper East Side.65
MEDICAL Hx:66 In general, good health67
1979, appendectomy68
1982, motor vehicle accident69 (passenger)70: hospitalized for three
days with back sprain, lacerations. No loss of
consciousness,71 physical rehabilitation for 6 months
1986-1990, severe headaches72 of unknown etiology CT Scan
negative, treated with cafergot and “pain killers”73
intermittently
1987, HIV-negative (reported)74
Allergies: penicillin (rash)75
Current medication: none76
20
(Note: Current medication in an admission interview reflects
medications patient is taking immediately prior to admission. You
might specify for patients in the hospital what their regimen is. In
this case she is taking Desipramine 150 mg p.o.q.h.s. (q.h.s. =
bedtime) and Haloperidol 2 mg p.o. q.h.s.)
MSE:
Appearance: Thin, pale white female with blond hair, appearing her stated age of 31, neatly
groomed, casually attired in a blouse and plaid skirt. Good eye contact. No
abnormal movements. Pleasant and cooperative.
Speech: spontaneous, slightly slowed, normal rhythm, soft tone
Affect: sad, constricted
Mood: depressed, “I still feel down”
Thought process: goal directed, logical, linear
Thought content: Continues to report feeling sad, hopeless, preoccupied with losing her job and
inadequacy as a mother. Now regrets making suicide attempt labelling it
“foolish” and “upsetting to her family”. Denies current suicidal ideation,
intent, or plan. No homicidal ideation, intent or plan. No hallucinations,
delusions, obsessions.
HIF: alert, oriented X 3
Concentration: fair, digit span 4->, 3<- with mistakes
Memory: immediate: good (immediate recall of 3 objects)
recent: 3/3 objects in five minutes
remote: Presidents BC->GB->RR->JC->GF->RN
Calculations: $1.50 = 6 Qtrs $1.35 = 37 nickels
serial 7’s 100->93->86->79->72->64->57
Abstracting ability: intact
similarities: apple/orange: “fruit”
table/chair: “furniture”
bird/plane: “fly”
proverbs: book by cover: “don’t judge people on the outside only”
Judgment: fair
Insight: good, knows she is depressed and wants help, no longer believes
people are plotting against her or that her husband is Satan.
SUMMARY:78 This 31 y.o. married, white, female lawyer, mother of 279, has a history of
several depressive80 episodes81 responsive to antidepressant medication.82
21
She has a strong family history for affective disorders.83 She now presents
following a serious suicide attempt after five weeks of depressed mood,
neurovegetative symptoms, diminished concentration, helplessness,
hopelessness, and paranoid delusions.84
PRINCIPAL Dx: Major Depression, recurrent, severe, with Psychotic Features85 (resolving).86
FOOTNOTES
Chief Complaint
1. This means the patient has had a total of 3 psychiatric admissions in her life, 2 of which
were at a hospital other than PWC. If the patient does not know how many admissions she
has had you might begin with “This is the 1st PWC admission and one of several psychiatric
admissions….”.
2. At a minimum you should include age, race, sex, and marital status. You may wish to add
here the religion or ethnicity of the patient, her employment status, occupation, and current
living arrangement.
3. The CC should be written in quotes and is usually the patient’s verbatim answer to the
interviewer’s question, “What brought you to the hospital?” It might be a psychotic response
e.g. “I am the incarnation of Vishnu” etc. Some writers will substitute the phrase “admitted
for a suicide attempt” but verbatim answers are generally preferable.
Source of Information
4. Describe the source(s) of information e.g. patient, chart, family, treating physician and
reliability of the source. In this course, the source will usually be the patient exclusively.
History of Present Illness
5. It is important to comment on the baseline functioning of the patient prior to the onset of the
present “episode” of illness. For patients who are chronically ill you might say the patient
has a long psychiatric history and was in her usual state of health until five weeks…..
6. The onset of the present illness should be stated in a time frame and is usually when the
patient notes the beginning of symptoms. You will need to use your own judgment as to
when the illness began. For example, this patient could have initially talked about her
suicide attempt the day before admission. Only later in your interview would you realize
that depressive symptoms had begun 5 weeks earlier. For those with chronic symptoms you
may choose the onset of an exacerbation of symptoms as the time frame e.g. the patient was
in her usual state of poor mental health until five weeks prior to admission when she noticed
worsening auditory hallucinations.
7. It is important to show the progression or worsening of symptoms.
8. One could also substitute psychiatric terms here e.g. she developed anorexia.
9. Weight loss, an important medical and psychiatric symptom, should be quantitated in
amount and over what period of time. If the patient was deliberately dieting, it should be
noted.
10. It is useful to insert other symptoms that complete the clinical picture.
22
11. Comment on how the illness affects her social role and functioning.
12. One might choose to list negatives pertinent to the clinical picture here. Pertinent negatives
of a more general nature can be listed at the end to avoid unduly disrupting the narrative
flow.
13. Provide some sense of time sequence.
14. Describe effects on occupational role.
15. Describe effects on daily activities and interests e.g. this shows the patient had developed
anhedonia.
16. Do not neglect mention of medical symptoms (i.e. this patient could have a brain tumor)
which may be part of the psychiatric syndrome or even causative .
17. Describe as you would for any medical symptom – its duration, location, quality, severity,
time of onset. Note also what the patient did (i.e. she took aspirin) and what the response
was.
18. Another way to phrase this sentence is She developed pan-insomnia and early morning
awakening.
19. Report why (insomnia), with whom (Dr. Highfee) the location, level, and background of
training (a private psychiatrist) of physicians or health professionals consulted.
20. Notice phrasing here. This has legal ramifications. The patient reported Dr. Highfee said
she was depressed. This is preferable to Dr. Highfee diagnosed depression unless you have
personally spoken to Dr. Highfee to confirm his diagnosis.
21. 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
four times a day). It is best to state the drug’s name if the patient can remember it. In some
cases you may have to say he prescribed a drug. State the prescribe regimen if known.
22. Describe how the patient reports actually taking the medication. What is prescribed and
what is actually taken are not always the same.
23. If you know an actual blood level, report it, as it is useful information. This is true of
any test e.g. chest x-ray, CT scan etc. Remember to report as you know the facts e.g. Dr.
Highfee reported the blood level to be 0.70 mg/ml or the chart indicated the blood level was
0.70mg/ml or Dr. Highfee said the blood level was “therapeutic”.
24. Indicate the response. Dr. Highfee, had he been called by you, might have said she did
respond.
25. Indicate side effects. They are useful to know for your own treatment plan.
26. Indicate her compliance.
27. This is useful because it suggests the patient may be secretive or unreliable or
uncooperative.
28. Mention additional symptoms that evolve.
29. Always mention a history of violence and the outcome in a psychiatric history.
23
30. This is useful because it tells you this episode was unusual by history and also mentions the
past history of violence.
31. This answers why the patient was not further involved with Dr. Highfee.
32. Describe recent stressors or events that may serve as precipitants for additional behaviors or
symptoms. Do not infer causality. That is, do not say she was placed on probation and
because of this became suicidal.
33. This describes the patient’s reaction to the stressor and, in effect, justifies your notion that
probation was a stressor. Remember what would seem stressful to you is not always to the
patient, and vice versa.
34. It is useful to describe the events right before admission in greater detail.
35. Any suicide attempts (also violence or bizarre behaviour) should be described in detail.
Note this sentence conveys the steps the patient took to avoid intervention (e.g. waited for
husband to go to work, locked herself in her bathroom, etc.). You should report what the
patient took, the amount, and whether all pills were taken (i.e. some patients take only a few
and leave the rest either because of ambivalence about dying, or naivete about lethal
dosages).
36. Report what was going through the patient’s mind at the time and what her intent and
expectations were.
37. Describe whether the patient tried to obtain help herself after attempting suicide, or more
ominously in this case made (or was unable to make) no attempt to seek help. You might
also comment here, if not in the past psychiatric history section, whether the patient had
made previous suicide attempts in her life.
38. Describe the patient’s response or clinical state. Note: the husband found her lying on the
floor is more accurate than she had fallen to the floor.
39. Always describe how the patient got to the hospital. In many cases the patient comes
voluntarily at the urging of a psychiatrist. Others may just decide on their own to go.
Others are “dragged” in by family.
40. Describe the patient’s condition on arrival if this is relevant.
41. List other recent stressors (both chronic and acute) which may be relevant to the clinical
presentation.
In the remaining section it is important to add pertinent negatives.
42. List pertinent negatives of other psychiatric symptoms. This is most important in
formulating a differential diagnosis. It is unclear until this point, for example, whether this
patient’s depression is unipolar or bipolar or whether she has additional psychiatric
disorders. Remember a patient can have more than one disorder. This list of negatives also
indicates to the reader that you asked about these symptoms rather than overlooked them.
43. List pertinent medical negatives. This should also include negative neurologic symptoms
e.g. head trauma, seizures, etc.
24
44. Always report the usual pattern of alcohol consumption and how that pattern has changed.
Try to be as specific as possible. For alcoholic patients, state when the last drink was. This
is important diagnostically and therapeutically. You may need to place the patient on
precautions for withdrawal. In addition, many patients with mental illness have comorbid
(i.e. co-occurring) alcohol or substance abuse.
45. As for alcohol, describe pattern of use of psychoactive drugs. Remember “legal” drugs, e.g.
benzodiazepines, can be abused, and can also be obtained illegally.
Psychiatric History
46. List the history chronologically, documenting as best you can diagnosis, clinical
presentation, type and duration of treatment, and response.
47. Include counseling, psychotherapy. If possible, describe type of therapy, e.g. cognitive
therapy, behavioral desensitization, “herbal” therapy, etc. If possible, indicate reason for
seeking therapy.
48. List medication, dosage regimen, if possible, with response. Provide name of treating
doctor. This will facilitate your contacting this doctor for additional information.
49. Always list suicide attempts or non-suicidal self-destructive acts. If possible, provide details
regarding circumstances and method of attempt, degree of injury sustained, and treatment.
List name of hospital to facilitate obtaining additional charts.
50. Document all hospitalizations with their duration and treatment modalities. Be sure to
inquire about electroconvulsive therapy (ECT).
Family History
51. Interpretation of the genogram: The patient’s father (a high school teacher), died in 1980 at
age 53 of a heart attack. The patient’s mother, age 63, is a retired schoolteacher. She
married a real estate broker in 1981 but then divorced in 1990. The patient had four
siblings. Her sister who had a history of depression committed suicide in 1990 at age 33.
Her older brother, age 39, has “manic-depressive” illness and alcoholism. The patient has 2
younger brothers, age 25, who are identical twins, one of whom has Crohn’s disease. The
patient is married to a lawyer, age 31. They have an 8-month-old daughter and 3-year-old
son.
52. Indicate other family members who may not be described in the genogram who have had
mental illnesses or made suicide attempts (or who have important genetic diseases e.g.
Huntington’s disease, etc.). If possible, describe the diagnosis, treatment response, age when
diagnosed (this is not often known by the patient).
Social History
53. Note this is probably more extensive than you may obtain in a single interview.
54. General description of family structure, social class, culture, location.
55. Note abnormalities, if any, in development, e.g. delays in speech, walking, etc.
25
56. Describe parents’ occupations and how patient perceives relationships with them.
57. Describe type of school, academic performance, special interests (indicate if patient failed,
was disciplined, or truant, or dropped out).
58. Indicate major family events.
59. Indicate moves or family separations.
60. Mention trouble with the law, legal difficulties, arrests, if any.
61. Summarize work history, including promotions, reasons for leaving or termination, job
satisfaction.
62. Describe interpersonal relationships with others from childhood. Indicate if patient was
socially withdrawn, promiscuous, etc.
63. Describe reasons for break-up.
64. Although some of this data is mentioned in the family history, it is repeated here only
because it had a particular emotional impact on the patient. Note that the patient’s oldest
brother has manic-depressive illness, which is not described here because it may not have
had as much of an impact, and it is appropriately mentioned in the family history.
65. Describe current living situation. Also, it would be important to mention all children,
including those out of wedlock, if any, and abortions.
Medical History
66. Can be reported as a chronological list.
67. Summary statements about overall state of health can be useful.
68. List major surgery (document complications, if any).
69. Report significant accidents and their treatments.
70. Passenger status is mentioned because some accidents are disguised forms of suicidal
behavior.
71. Comment on head trauma.
72. Comment on neurological symptoms.
73. If doses and duration are known, report them. Some patients can only remember receiving a
“pill” or a “pain killer”. You might also mention name of family doctor.
74. Report major tests.
75. Describe the type of allergy e.g. rash, anaphylaxis, urticaria, if possible, Some patients
improperly consider a side-effect to be an allergy.
76. List current dosage regimen, if applicable.
26
Mental Status Exam
77. This will not be annotated here. Consult Chapter 1 and 2 of the text.
Summary
78. Provide one or two sentences that summarize the main epidemiologic risk factors, historical
data, including treatment, response, current clinical presentation and data on longitudinal
course that allow you to arrive at your diagnostic impression.
79. This reiteration of demographic data is important. Depression is more common among
young females. The mention of married lawyer and mother of 2 suggests relatively high
functioning which would be inconsistent with other diagnoses e.g. schizophrenia.
80. The previous mental illness e.g. depression makes it more likely that the current illness is
depression.
81. Episode connotes a brief period of illness and gives information about course. For a
schizophrenic you might have said with a long deteriorating course.
82. Although it is not foolproof, treatment response is a reasonable “post hoc” confirmation of a
diagnosis.
83. Family history is a strong epidemiologic risk factor for the type of mental illness.
84. Summarize important symptoms at the time of presentation.
Principal Diagnosis
85. Write what you believe is the principal diagnosis. The diagnosis is usually specified by
DSM-5 criteria, which often distinguishes between single episodes versus recurrent, level of
severity, and presence or absence of psychotic features.
Note: If you just read the MSE only, you would note that the patient was not psychotic at the time
she was interviewed. Presumably she had been treated for her psychotic features. This
underscores the importance of not relying on cross-sectional data, but rather diagnosing
based on disease course.
86. Her illness is improving.