Writing Up the Results of ˜ the Interview

I’ve had a long and stormy relationship with the dreaded write-up. During medical school, the requirement of a novellength write-up was a welcome reprieve from the stresses of rounding on patients and making oral presentations. In residency, I became annoyed with the write-up, which seemed a pesky intrusion into the limited time I had to spend with patients. At the end of a long day, I would sit down heavily at the Dictaphone and try to gather my thoughts, hoping that the resulting transcription would be coherent.

It wasn’t until I had been in clinical practice for a few years that I came to terms with the write-up. Having come full circle, I’m back to (sort of) liking it, viewing it as a welcome few minutes of quiet thought and synthesis between patient appointments.

I hope this chapter helps you to work through some of the more painful moments in your own relationship with the write-up. I outline some formats for you to choose among, and I provide some tips to help you streamline the process.

Every write-up represents a balancing act among three objectives:

Thoroughness
Time-efficiency
Readability

The ideal write-up incorporates all three objectives. It is thorough enough to document the basis for a diagnosis and treatment plan; it does not require so much time that it would be unfeasible for a busy clinician to produce; and it is not so lengthy as to provoke sighs from equally busy colleagues who must read the write-up because of their involvement in the patient’s treatment.

In general, a write-up should not take you more than 10 to 15 minutes to produce, whether you dictate it or write it yourself. It should not be longer than two or three typed pages if you really want colleagues to read it.

IDENTIFYING DATA

The identifying data should be a fairly long initial sentence that sets the stage for the entire evaluation. You want to not
only identify who the patient is, but also to locate her within the context of social and cultural norms. This includes age, sex, marital status, and source of referral at a minimum and may include other information such as occupation, living situation, and presence of other family.

This is a 45-year-old, twice-married woman with two grown children, who is an accountant for her husband’s carpet cleaning business, and who was referred by her primary care doctor because of increasing anxiety and the possibility that she is abusing anxiety and pain medication.

This is a 29-year-old, single, white man on psychiatric disability, living in a group home downtown, with a long history of paranoid schizophrenia, who was admitted to the hospital after group home staff members found him in the process of drinking a bottle of methyl alcohol in an apparent suicide attempt.

CHIEF COMPLAINT

The chief complaint should be a verbatim sentence of the patient’s, usually in response to your question as to the reason he is seeking help.

My wife made me come here. There’s nothing wrong with me. My mother just died. I can’t deal with it.

I just figured it was time to see a therapist to work out some issues.

Each of these statements reflects a different sense of purpose and urgency for treatment, and consequently, this information is helpful in setting the stage for the report to follow.

HISTORY OF PRESENT ILLNESS

In Chapter 14, I describe two different definitions of the HPI, one referring to the history of the illness, which may begin years before the interview (history of syndrome approach), and the other referring more narrowly to events of the past few weeks (history of present crisis approach). Which definition to use is a matter of personal or institutional preference. Following are examples of both approaches.

History of Syndrome

Mr. M has a long history of bipolar disorder, beginning in his junior year of college. He was hospitalized for manic behavior, which included studying for days at a time to the point of exhaustion. In addition, he exhibited grandiose, disorganized behavior when he “occupied” the chancellor’s outer office and stated that he was the chancellor of the university. He was started on lithium at that point and did well for several years, until he had a series of hospitalizations in the early 1990s for depression and alcohol use after a divorce from his wife.

His last hospitalization was 2 years ago for depression, and he has done fairly well since then, taking medications [venlafaxine (Effexor) and valproic acid (Depakote)] and going to regular therapy and medication appointments.

History of Present Crisis

Mr. M has a long history of bipolar disorder with several hospitalizations but had been doing fairly well for the past 2 years until about 2 weeks ago, when his girlfriend noticed a pattern of manic behavior, which began after a promotion to a new position at his company. He has slept an average of 3 hours a night because of a need to “prepare for his day,” he has been talking more rapidly than usual, and he has been making unrealistic plans to become the president of his company. He consented to this admission on the advice of his girlfriend and his outpatient caregivers.

PAST PSYCHIATRIC HISTORY

The nature of the PPH section of your write-up depends on how thorough you have been in the HPI. Generally, the PPH is a time to go into some detail on what sort of psychiatric treatment your patient has had in the past. In Chapter 15, I recommend the mnemonic Go CHaMP as a way of organizing your questioning, and you can also use this for your write-up. You can begin with a General statement, such as

The patient feels that he has received fairly intense, and overall successful, treatment for his depression over the years.

The patient has started treatment at various times but by his own admission has been generally noncompliant.

In CHaMP, the C is for current Caregivers, if any. Documenting Hospitalizations is straightforward, and usually the detail is limited by your patient’s memory. Noting the date of the last hospitalization is important, because it has implications for the severity of the current problem. Having a separate heading for “Medication trials” is often very helpful, both for other caregivers and for easy reference if you have to make a medication change several months or years after the first visit. Finally, documentation about past Psychotherapy should include a note about whether the patient found it helpful and why or why not.

SUBSTANCE USE HISTORY

Where in the evaluation should you document history of substance use? This varies by practitioner, with some including it in the PPH, others in the social history, and still others in the medical history, usually under “habits.” My preference is to use a main heading devoted to the issue, because it is such an important and often overlooked part of the psychiatric history.

Under substance use, I include tobacco and caffeine use, as well as the usual array of more insidious substances, such as alcohol or cocaine.

REVIEW OF SYMPTOMS

The review of symptoms is where you can really impress your readers with your diagnostic thoroughness. Simply go through the major diagnostic categories, indicating whether the patient met any of the criteria and excluding those that you already mentioned in the HPI and in the substance abuse section, if you have included one.

On review of psychiatric symptoms, the patient denied any history of mania or hypomania. She described a history of frequent panic attacks in the past, with some accompanying agoraphobic avoidance, but said that these events had abated spontaneously 2 years ago. While she considers herself a “perfectionist,” she denied frank obsessions or compulsions. There was no history of eating disorders, ADHD, somatization disorder, dissociative disorders, or psychotic
phenomena. With regard to PDs, there was a hint of dependent traits in her description of her relationships with her husband and her best friend.

FAMILY HISTORY

If you draw a genogram directly on the evaluation form, this will suffice for the family psychiatric history, although you may want to add a one-line comment to highlight some facet of the history, such as

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