Psychiatry Clerkship Patient Write-Up

As in many other clerkships, in the Psychiatry Clerkship we evaluate each student’s ability to 1)
write up a history and physical exam and 2) document clearly a discussion of differential
diagnosis and a treatment plan. The write-up should include pertinent identifying data (NOT the
patient’s name or medical record number), chief complaint, history of the present illness, past
psychiatric history (if applicable), past medical history, family history, detailed personal/social
history, pertinent findings on physical exam, and a complete mental status examination. This
should be followed by a discussion of the complete differential diagnosis (Include psychiatric
and medical diagnoses on the differential and discuss all pertinent psychosocial contributors)
and outline of a treatment plan (biological, psychosocial and social). Dr. Villanueva will assign a
score from 0-5; they will be returned by the end of the clerkship.

PLEASE SUBMIT AS A WORD DOCUMENT

Write-Up Rubric

0 Write-up not submitted, evidence of plagiarism, and/or grossly lacking in detail in

Points the history and physical. No discernible clinical reasoning.
1 History and Physical lacking important details, little if any evidence of clinical
Point reasoning in the assessment and treatment plan. Treatment plan lacking 2 or more
elements of components: Safety, Biological/Medical, Psychological, Social
interventions.
2 History and Physical lacking some detail but critical information included. Some
Points clinical reasoning included in the assessment and plan. Treatment plan lacking 1 or
more elements of components: Safety, Biological/Medical, Psychological, Social
interventions.
3 History and Physical contains sufficient detail but with poor readability/flow. Clinical
Points reasoning is basic, missing some potential considerations in the differential
diagnosis. Discussion of clinical reasoning is present but brief. Treatment plan
lacking 1 or more elements of components: Safety, Biological/Medical, Psychological,
Social.
4 History and Physical contains sufficient detail, reads well. Most potential
Points considerations in the differential diagnosis included. Treatment plan covers elements
of components: Safety, Biological/Medical, Psychological, Social, but with little detail.
Discussion of clinical reasoning is present and based on findings obtained from
history and physical and laboratory data/testing.
5 Detailed History and Physical, reads well and is pertinent. Laboratory/study results
Points included when applicable. Comprehensive differential diagnosis covering psychiatric,
medical and psychosocial issues. Treatment plan covers elements of components:
Safety, Biological/Medical, Psychological, Social interventions in detail. Discussion of
clinical reasoning is present and based on findings obtained from history and physical
and laboratory data/testing and also includes references.