School of Nursing and Allied Health
MSN Case Write Up Assignment
The purpose of the Case Write-Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.
Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.
Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, add an addendum at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice. Be truthful in your writing. If you realize that you forgot to evaluate something or teach a certain part of the lesson, you can add an addendum to the end of the paper explaining what you should have done. Your clinical instructors don’t expect you to have perfect write-ups, but they do expect you to use every patient encounter and write-up that follows as a chance to learn, evaluate, and improve your own practice.
If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write an addendum at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum.
You are learning to practice evidence-based practice. Support the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your write up is using a research article. Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)
Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups
All case write ups are to be submitted to the appropriate assignment category by the due date. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date.
When submitting case write up in Blackboard, the assignment will submit to a plagiarism detection software. The plagiarism detection software is used by HBU to identify plagiarized assignments. We are aware of the difference between high “copy matches” due to copied things such as titles/headings and significant matches that were inappropriately copied from another paper. Unfortunately, we have seen some of the latter and it is generally not difficult to tell the difference between the two since we can immediately see every word of the other papers. If a paper has significant or complete sections of copied material, a grade of zero will be assigned to the paper.
Episodic Write-up: Episodic visits are mostly encounters which involve one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally. Episodic visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected. Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.
This write-up should be 2-5 pages (excluding title page and reference list) and concentrate on the most pertinent information. Not all the systems or sections will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best/most important tools and information to justify your critical thinking.
Comprehensive Write-up: Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam (may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc. This write up should be 5-8 pages (excluding title page and reference list).
You must know how to delineate which visits are episodic versus comprehensive. Conducting a comprehensive exam on a patient whose chief complaint and ROS support an episodic visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning/judgment (diagnosis/plan of care) if they perceive you are all over the place! Insurance is not going to pay you more because you decided to complete a comprehensive note on an episodic visit or diagnosis!
Alternative Write-up: Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process. These write ups will follow the same guidelines as comprehensive-write ups.
This assignment is designed to promote the development of the following: AACN Essentials (2022): Domains 1, 2, 4, 6, and 9 and NONPF NP Core and Population-Focused Competencies (2012;2017): Scientific Foundational, Practice Inquiry, Technology and Information Literacy, and Independent Practice.
Case Write-up Outline
Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.
Subjective:
CC: This should be in quotes: “I’ve had a cough and sore throat for 2 days”
HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.
Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.
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 (why are they taking it?). Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history. If a patient is taking Metformin and there’s no related information on the history and/or diagnoses list, something is missing.
Allergies: Medications, Food allergies when applicable. Specify what type of reaction next to the allergy if known by the person you are collecting history from (E.g., Penicillin-rash)
Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For pediatrics: list dates for all immunizations.
Other pediatric considerations: list who all lives in home with patient, how many siblings with ages next to them, type of home, any pets inside/outside home & what type of pet, any smoking in home, any guns in home; if young child: are they in daycare or if babysitter or family member or parent stay home with child, are they in school & what grade and what type of grades the child makes, list any extracurricular activities, any problems with school or teacher, any recent social or home changes. If they are pre-teen and older- add alcohol use, smoking, sexual history, work history, etc.
Family History: It is generally appropriate to go back at least two generations. State family member (mom/dad/maternal grandparents/paternal grandparents/siblings/etc.), their age & if they’re alive, write unknown if history not known, write any conditions or illnesses next to each person, if they are deceased write deceased and any illnesses/conditions for them also.
Obstetrical History: When appropriate, document number of pregnancies and other relevant information.
Birth History – applicable for pediatric write ups especially for young pediatric patients
Review of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. Nutrition should be addressed, especially in pediatric patients. In childbearing women (any teen or female who have reached menarche), make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy). Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit). For a young teen you can put “not sexually active” (but make sure you have asked). This is sometimes tricky with teens being seen for general health problems but so very important. If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.
Objective
Vital signs (BMI should be included on every visit)
Physical examination
• Episodic exam: make sure that you detail your findings for each system pertinent to your Chief Complaint. E.g., if you have a child pulling on their ears, it will NOT look good if you do not document an ear assessment or otoscopic examination in your physical exam for your write-up.
• Comprehensive exam: This is head to toe detailed and thoroughly describe findings within ALL systems.
Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.
TIP:
Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results. Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section. Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.
Assessment
List both your differential diagnoses and your presumptive diagnosis – include appropriate ICD-10 codes for all diagnoses. Remember that these should be supported by findings in your history and physical exam. For a comprehensive visit, you should document at least three ICD code diagnoses. Occasionally, a comprehensive visit merits a differential diagnosis list. If your ROS or physical exam findings reveal abnormalities, the abnormalities need to be addressed.
Please remember support your indicated diagnoses with evidence-based reference: provide citation and supportive information.
Plan
Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed. Please be sure this information is organized under each diagnosis; keeping it organized helps the write up flow well to where the reader is able to get a clear picture of everything you did during the patient encounter.
Coding Resource:
All write ups should include the billing codes. We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up – do not forget to include both the E&M code (level of service). Your E&M code should be consistent with your patient visit.
Addendum
***Remember to add an additional note at the end of the write up if you realized anything was missing from the encounter that should have been done or ordered. Put it at the end of your write up and label it: Addendum ***
MSN Case Write-Up Rubric
Criteria Exceeds Expectations Meets Expectations Below Expectations No Effort
Chief Complaint
(CC) 3 Points
• Includes the reason for visit
• CC is appropriate for the type of write-up
• CC is in the patient/family’s own words. 2 Points
• CC is not in the patient/family’s own words
1 Point
• CC is not appropriate for the type of write-up 0 Points
• Not included
History of Present Illness
(HPI) 10 points
• HPI is comprehensive and includes all the pertinent information and excludes irrelevant information.
• HPI is focused and detailed.
7 points
• Missing 1-2 key components
OR
• Includes information that is irrelevant to the patient visit. 4 points
• Missing 3 or more key components
OR
• HPI is not focused and lacks details 0 Points
• Not included
Medications 3 Points
• Medication list is comprehensive and includes scheduled and PRN drug name (brand and generic), dosage, route, frequency and indication.
• Allergies are documented and includes reaction.
• Includes NDKA, if applicable. 2 Points
• Omits 1-2 details.
OR
• Allergies are documented but does not include reaction. 1 Point
• Omits 3 or more details.
OR
• Allergies are not addressed 0 Points
• Not included
Pertinent History 10 Points
• Provides comprehensive past medical history, surgical, family, social, obstetrical history, and birth history (when applicable).
• History is consistent with other documentation.
• Includes immunization information
7 Points
• Omits 1 -2 pertinent details
4 Points
• History presented is superficial
OR
• Omits 3 or more pertinent details
0 Points
• Not included
Review of Systems 10 Points
• ROS is completed in a systematic fashion
• For episodic visit:
1. ROS addresses at least 4 systems. 2. ROS is specific to the patient’s problems and likely differential diagnoses
• For comprehensive visit: each system is addressed completely
• Does not include any objective data
• Do not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’ 7 Points
• Misses 1-2 components
OR
• ROS includes inappropriate systems for an episodic visit
4 Points
• Misses 3 or more components
OR
• ROS includes objective data
0 Points
• No ROS attempted
Objective Data 18 Points
• Documents vital signs with BMI included
• For episodic visit:
1. PE addresses at least 4 body systems
2. PE is specific to the patient’s problem and likely differential diagnoses
• For comprehensive visit: each system addressed completely
• Includes pertinent positive and pertinent negative findings.
• Does not include any subjective data
• Documents labs, diagnostic tests that are available for that visit.
• Do not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’ 12 Points
• Documents vital signs but is missing BMI
OR
• Missing 2-3 components, pertinent positives/negatives
OR
• PE includes unnecessary systems for an episodic visit
OR
• Plan includes subjective data
OR
• Documents labs, diagnostic tests that should be a part of the plan
6 Points
• Does not document vital signs
OR
• Missing 4 or more of the components, pertinent positives/negatives
OR
• Includes unnecessary systems for an episodic visit
OR
• Addresses less than 4 systems for an episodic visit
• Fails to document labs, diagnostic tests
0 Points
• Not included
Assessment 16 Points
• Provides 3 or more differential diagnoses and a presumptive diagnosis for an episodic visit.
• Provides at least 3 diagnoses for a comprehensive visit
• Diagnoses are accurate and appropriate for the patient visit
• ICD-10 codes included with each diagnosis 10 Points
• Provides only 2 differential diagnoses for an episodic visit
OR
• Provides less than 3 diagnoses for a comprehensive visit
OR
• Fails to provide differential diagnoses for abnormal findings in a comprehensive visit
• Does not include ICD-10 codes
6 Points
• Provides only 1 diagnosis for an episodic visit
OR
• Diagnoses provided are not appropriate for the patient visit
0 Points
• No effort
Plan 20 Points
• Plan is thorough and includes appropriate labs/tests ordered that are pending
• Includes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included.
• Plan includes both pharmacological and non-pharmacological interventions
• Plan includes referrals (when applicable) and follow up details
• Orders are appropriate for patient visit.
• Citations for sources of interventions
• Coding and Billing included
15 Points
• Missing 1-2 components
OR
• Does not include Coding and Billing
10 Points
• Plan is superficial
OR
• Missing 3 or more components
OR
• Plan is not supported by evidence and citations for sources of intervention are missing 0 Points
• Not included or inappropriate to patient visit
Formatting/APA 10 Points
• No errors in grammar and spelling .
• No errors in APA format
• Write-up is in proper format and adheres to the appropriate page limits. 7 Points
• 1-2 spelling or grammar errors
OR
• 1-2 APA errors 4 Points
• 3-4 errors in spelling or grammar
OR
• 3-4 APA errors
OR
• Write-up is not in proper format
OR
• Write-up does not adhere to the appropriate page limits
0 Points
• 5 or more errors in spelling or grammar
OR
• 5 or more APA errors
