Case report template Dr Damian Fogarty

Each clinical attachment in Phase 3 has associated clinical case(s) to complete as part of the attachment + the overall year 3 assessment. The 15 cases contribute 15% of the year/module To assist the learning experience of these cases we are now using a 10 page blank template on which the case should be hand written rather than word processed.

Template adapted from an admission form used in the Belfast Trust and that used by the Royal College of Physicians Hand written entries remain the main method of charting patients progress in hospitals. Use of hand-written notes will be quicker and more uniform for students to complete and assessors to mark. More time spent near patient/on ward to complete More accurately reflects the full spectrum of issues in a hospitalised patient More timely feedback closer to the attachment Avoids plagiarism Writing up a case is essential preparation for your transition to junior doctor

Patients approached on the ward attachment Cases often suggested by teachers If not ask the doctors for “a good case” Begin early to identify your patients

Begin early to identify your patients and cases Define adequate time and use parts of the template at the bedside e.g drug lists, systems review For areas that may need refined/edited use rough notes before finishing, HPC, discussion etc Ask for help from the junior doctors especially the ones who know your patient Conclusions