Transcript Introduction to Case "write up" template

Case report template
Dr Damian Fogarty
• Each clinical attachment in Phase 3 has
associated clinical case(s) to complete as part of
the attachment + the overall year 3 assessment.
• The 15 cases contribute 15% of the year/module
• To assist the learning experience of these
cases we are now using a 10 page blank
template on which the case should be
hand written rather than word processed.
Writing up a case is essential preparation for your
transition to junior doctor
• Template adapted from an admission form used in
the Belfast Trust and that used by the Royal College
of Physicians
• Hand written entries remain the main method of
charting patients progress in hospitals.
• Use of hand-written notes will be quicker and more
uniform for students to complete and assessors to
mark.
• More time spent near patient/on ward to complete
• More accurately reflects the full spectrum of issues
in a hospitalised patient
• More timely feedback closer to the attachment
• Avoids plagiarism
• Patients approached on the ward attachment
• Cases often suggested by teachers
• If not ask the doctors for “a good case”
• Begin early to identify your patients
Conclusions
• Begin early to identify your patients and
cases
• Define adequate time and use parts of the
template at the bedside e.g drug lists,
systems review
• For areas that may need refined/edited use
rough notes before finishing, HPC,
discussion etc
• Ask for help from the junior doctors
especially the ones who know your patient