Feedback will consist of narrative comments, corrections, and suggestions and an overall rating
as described below: Preceptors will attend to the following criteria in evaluating the quality of
a. Punctuality
b. Adherence to specified format with correct organization of data.
c. Write-up is neat, legible, and with few spelling errors..
d. Write-up accurately reflects what the patient reported during the interview.
e. Thoroughness (this will be evaluated in light of the amount of information provided in
the interview e.g. it is expected that much information will not be covered by the
f. Correct use of medical and psychiatric terminology
g. Conciseness, i.e. write-up is not long-winded, rambling, or filled with extraneous detail.
Please edit your work before turning it in.
NOTE:Your ability to arrive at the correct diagnosis is not the major criterion for
evaluation. We are trying to help you learn to take, and then report, an
accurate and thorough psychiatric history and evaluation. You will learn
diagnostics more fully in your clinical clerkship.
Rating Scale
Outstanding: Adheres to specified format within correct organization of data; neat with no
grammar or spelling errors; accurate reflection of patient report; thorough, but concise; correct
use of medical/psychiatric terms, AND PUNCTUAL.
Excellent: Adheres to specified format with minor errors in organization; no grammar or
spelling errors; generally reflects patient report; generally thorough (left out a few minor
points) OR a bit rambling with some unnecessary detail; correct use of medical/psychiatric
Good: Some errors in adhering to format or organization, and/or some grammar/spelling
errors; missing a few major points or rambling with unnecessary details; some errors in
medical/psychiatric terms AND PUNCTUAL.
Fair: Some problems adhering to format; major errors in organization of data; grammar or
spelling errors; incomplete, missing some major points; some incorrect use of terms and/or
handed in LATE.
Unsatisfactory: Does not adhere to specified format or data poorly organized; some
grammar/spelling errors; poor reflection of patient report; incomplete; some incorrect use of
terms, and/or LATE.
• See the attached sample annotated write-up.
• Leave at least 1 inch margins on top, bottom, right and left to allow space for
written comments by preceptors.
• At the top of the page, put your name, your preceptors’ names, date of interview
(DOI), date the write-up is turned in, and the number of the write-up (the practice
write-up is write-up #1.)
• Type or handwrite neatly.
– single space within paragraphs
– double space between paragraphs
– triple space between sections
• Do not use the name of the patient in the write-ups. Use a letter instead (Mr. A or
Ms. B., etc.)
• Organize the write-up into discrete sections with the following labels:
– Chief Complaint (Identifying Data & Presenting Problem)
– Source and Reliability
– HPI (History of Present Illness)
– Past Psychiatric Hx (Psychiatric History)
– Family Hx (Family History)
– Personal/Social Hx (Personal History)
– Medical Hx (Medical History including allergies & current medications)
– MSE (Mental Status Exam) [See Sample for organization]
– Summary (Summary of Clinical Data)
– Principal Dx (Principal Diagnosis)
• Staple all pages in the upper left hand corner.
(The case is entirely fictional)
This write-up is very detailed for illustration. The level of detail is more than you can extract
from an average patient in less than an hour, but it should give you an idea of what data are
useful, as well as how to organize your own write-up. For example, it also reflects what might
be typically obtained from patients or their charts, given more time. Ideally, you would want to
know many specific details about treatment, but often the patient cannot recall them extensively,
or chart data are missing.