Please be sure to include the date of the write-up at the beginning, your name and PO Box number at the end, and the patient's name and hospital number on each page. Make sure these critical pieces of information are legible. Inpatient write-ups should be turned in within 24 hours. Outpatient write-ups should be turned in within 48 hours to the attending to whom you presented, together with chart and other patient documents. Your write-up is used to assist the attending to dictate a letter to the referring physician.
Radiological studies are to be returned to the patient.
You are not obliged to write up more than two patients per clinic. These forms are the basis for your clinic grade. Progress notes, both inpatient and outpatient, should be succinct and problem oriented. There is no need to provide a comprehensive review of all available data on the patient, only information that is pertinent to the major clinical issues at hand. Clinic follow-up notes should include a brief paragraph on relevant history and a list of drugs and drug dosages.