Documenting the Interview
Your immersion interview will be documented using the standard structure of the complete medical database (below). The goal in Immersion is to become familiar with this structure and document information in the appropriate place. An example Immersion writeup is at the end of this chapter.
| ID/CC | Age
Chief concern and duration of symptoms Any known medical problems highly relevant to the chief concern |
| HPI | Background: Health at the time of symptom onset
Details of the presenting problem beginning at the onset and continuing chronologically until the time of presentation. Pertinent positives: Symptoms or health problems relevant to the diagnoses on your differential that your patient reports they have. Pertinent negatives: Symptoms or health problems relevant to the diagnoses on your differential that your patient reports they do NOT have Optional: Hospital course or evaluation to date |
| PMH | All active medical problems, including date of diagnosis, current treatment, control and complications for each.
Past problems relevant to current concern or ongoing health. Resolved, minor problems don’t need to be included. |
| Meds & Allergies | Prescribed medications and doses
Non-prescription medications and complementary therapies Drug allergies and the type of reaction |
| Health-Related Behaviors | Diet & exercise
Brief substance use history Brief sexual history |
| Family Medical History | Family history of illnesses and causes of death in first degree relatives |
| Social History | Full social history, including important influences on your patient’s health and health care. May include living situation, social support, occupation and avocation, any financial or other concerns, gender identity & sexual orientation, religious affiliation, etc. |
| Review of Systems | List all systems and note the presence or absence of each symptom you asked about. For organ system(s) discussed in HPI, write “see HPI”
Include details of positive responses to ROS questions (duration, severity, prior evaluation or treatment) |
Deeper dive: Identifying data and chief concern
The identifying data and chief concern (ID/CC) is the headline of your write-up or oral case presentation. It sets the stage for your patient’s story and frames your audience’s clinical thinking. If not chosen carefully, it could also promote assumptions or trigger implicit bias in your audience, or it could alienate your patient if they read or hear it.
Best practices for patient identifiers are evolving and you will encounter differences in various clinical settings and specialties. It would not be possible to generate guidelines that incorporate all of patients’ identities in the ID/CC and we acknowledge this reality and approach this task with humility.
In 2018, a workgroup of UWSOM students and faculty worked with the WWAMI community and local experts to establish guidelines for the use of patient identifiers in notes and case presentations. Based on this work, our recommendations for ID/CC are:
Always include:
Name
Ask your patient how they would like to be addressed and refer to them in that way. For FCM writeups, which will be submitted to Canvas rather than a highly secure electronic health record, do NOT include names and instead use made-up initials like “Mr. X” or “FX”.
Age
Always be included in the ID/CC since the prevalence of many diseases changes with age. The most likely causes of abdominal pain are very different in a 9 month old, a 9 year old and a 90 year old. Use an actual number rather than imprecise terms like elderly or middle aged, which are less accurate and might inadvertently offend your patient.
The chief concern
The symptom or problem that led to the hospitalization or the clinic visit today. Start with the reason for the visit as reported by your patient, in their words. To help narrow the list of possible causes of a new symptom, you can also include:
- descriptors of that symptom (like acute or chronic, mild or severe)
- other symptoms that seem to go along with it (like fever in patient with sore throat)
- known health issues that affect your clinical reasoning about the problem – we will work more on this next quarter.
In some cases include:
Gender and sex
Commonly included in the ID/CC but they are often not relevant to the clinical situation at hand. Gender refers to an internal sense of identity so should only be included in the ID/CC if it has been confirmed, for example on a clinic intake form completed by the patient or by asking about pronouns. Making assumptions risks mis-gendering patients and damaging the therapeutic relationship.
The words female and male refer to anatomic sex and are typically assigned to an infant at birth, based on appearance of external genitalia. In some clinical scenarios, your patient’s reproductive anatomy could influence medical decision making. In these cases, anatomic sex should be included in the ID/CC. Although some providers use ‘female’ or ‘male’ in most ID/CCs, this feels overly clinical or dehumanizing to some adults. We generally recommend against it at the bedside if anatomic sex is not relevant to the clinical concern. However, the plural “males” and “females” is used in research to designate populations.
Information regarding gender identity or assigned sex at birth (ASAB) can be included in the social history, and information regarding history of or plans for gender affirming care can be included in the past medical history.
In your block courses, you’ll see cases in which patients are identified by their chromosomal complement (i.e. ABC is a 23 year old 46, XX). This is appropriate for cases focused on patients’ genetics, but would not be appropriate for most clinical settings.
Rarely (if ever) include
Practice is changing, and you will see others include information in the ID/CC that we would generally recommend against.
Race
Race is a sociopolitical construct that does not accurately reflect genetic ancestry. However, racism and the health disparities it causes clearly impact patient outcomes. Both resources and stress are disproportionately distributed across racial categories. At a population level, information about race and ethnicity can help us to understand and address health disparities so health systems collect it to identify the populations served. When collected it should be the patient who designates the race.
For an individual patient, race is rarely relevant enough to the presenting concern to belong in the ID/CC headline. Routinely including race in the ID/CC perpetuates the myth that people of different races are biologically different, a myth many physicians and educators are working hard to counteract.
If there is a clear linkage between ancestry and a disease on your differential diagnosis, you could consider including this information in the ID/CC.
If your patient shares experiences with racism, especially in healthcare, these can be included in the HPI if relevant to the presenting concern or in the past medical or social history. A patient’s self-reported racial or ethnic identity is often recorded in a demographic section of the EHR but can also be included in the social history.
Sexual orientation and practices
Should only be included in the ID/CC if they are directly related to the presenting medical concern. Otherwise these can be documented in the social and sexual history sections of the write-up, using the patient’s personally-articulated terms for their sexual orientation identity.
Disability status
Should only be included in the ID/CC if it pertains to medical decision making for the presenting concern. Otherwise it should be documented in the problem list and past medical history. Person first language is usually preferred, for example ‘Sam is a 36 year-old with spinal cord injury‘ rather than ‘Sam is a paraplegic‘. However, some people and disability communities prefer identity-first language, i.e. ‘Sam is Deaf‘ rather than ‘Sam has a hearing impairment‘. Observe the language your patient uses or ask them their preferred terminology.
Size
Body size should only be included in the ID/CC if it is clearly pertinent to the reason for the visit, as when the patient’s chief concern is weight or weight change is relevant to the differential diagnosis. Although the body mass index (BMI) is imperfect, it is preferred over subjective terms such as “obese”, “morbidly obese” and “thin” which can be interpreted as judgmental.
Language matters!
As you document information about your patients, be thoughtful about the words that you choose. Electronic health record (EHR) notes can be copied forward and follow patients for years, and as more people access their own EHR, chart notes have more potential to offend. A poor choice of words can seed mistrust in the physician-patient relationship and in the healthcare system as a whole.
Your notes should not:
Cast doubt on your patient’s experience. You will often hear words like ‘claims or ‘denies’ or ‘believes that’ in the HPI. Although a clinician may use these words neutrally, others can hear them as doubtful. Instead, use simple statements like ‘has severe pain’ or ‘did not have nausea’ or ‘attributes the rash to soap’.
Imply that your patient is culpable for their medical condition. Most health problems have multiple contributors, and unhealthy behavior is often driven by social, structural, and mental health issues. Blaming the victim can decrease empathy and decrease our patients’ trust in us.
Include unnecessary descriptors or details that could bias other providers. Everyone carries implicit biases that have the potential to affect the quality of care that they provide. Reading that a patient is ‘non-compliant’ or ‘an ex-convict’ may change the way another provider thinks of them.
Imply or reinforce a stereotype that is racist, sexist, homophobic, transphobic or culturally unaware.
| Avoid | Instead use |
|---|---|
| Making the patient their disease, such as ‘he’s a substance abuser’ or ’36 y.o. diabetic…’ | Person first language, such as ‘has a substance use disorder” or “… with diabetes’ |
| Words that cast doubt on a patient’s experience: patient denies, claims, believes… | Neutral language that accurately relays the history: patient has, reports, states, attributes |
| Extraneous details that do not impact the presenting concern. | Pertinent details only. |
| Using pejorative, harmful terms like ‘vegetable’ | Appropriate disease terminology like minimally conscious state |
Stigma & Language
Stigma can arise from any attribute or behavior that may be socially discrediting, and stigmatizing language can perpetuate bias and healthcare disparities. People with stigmatizing conditions like substance use disorder, chronic pain, and obesity are particularly affected by the language their providers use.
In one study, highly trained clinicians attending a mental health conference were presented with two different versions of the same vignette. One used the term ‘substance abuser’ and the other ‘has a substance use disorder’. Those who read ‘substance abuser’ saw the patient as more personally culpable for their condition than those who read ‘has a substance use disorder’.
This video is from “Addiction Treatment: Clinical Skills for Healthcare Providers,” a Yale/Coursera course. Many of you have already seen physicians use stigmatizing or biased language. This is an area of culture change within medicine – if you hear it from us, your mentors and teachers, we would appreciate your feedback. And as you continue your training, maintain this awareness and resist adopting language that does not support your patients.
Less stigmatizing language for specific content areas
| Avoid | Use | |
| Adherence | ‘Non-compliant’ or ‘didn’t show up for…’ | ‘Has not been taking medication because –‘ or
‘Unable to make a follow up appointment because –‘ |
| ‘Refuses’ (intervention) | ‘Declines’ (intervention) | |
| History | ‘Poor historian’ (many patients are not able to provide all of the information we’d like to gather) | ‘Patient could not recall…’
‘Unable to provide history due to somnolence’ or severity of illness, dementia, etc. |
| Disease control | ‘Poorly controlled’ may imply culpability | ‘Not at goal’ |
| Substance use | ‘Substance abuser, opiate addict, alcoholic’ | ‘Person with substance, opioid, or alcohol use disorder’ |
| Drug test was ‘dirty’ or ‘clean’ | ‘The test showed X’ | |
| Mental health | ‘Crazy’ | SF has a known diagnosis of bipolar I disorder |
| ‘Committed suicide’; ‘successful suicide’ | ‘Died by suicide’ | |
| Disability | Words which imply decreased agency for people with disabilities | Patients’ own descriptions of their disabilities |
| ‘Wheelchair-bound’ | Wheelchair user | |
| ‘Retarded’ | Intellectual disability | |
| ‘Suffers from’ or ‘is afflicted by’ (disability) | ‘Has (disability)’ | |
| Social history | ‘Homeless’ | ‘Experiencing homelessness’ or ‘unhoused’ |
| ‘Ex-convict’ | If relevant to the presenting concern ‘with a history of incarceration’ | |
| Gender | Assuming or not asking about gender identity | When relevant to care, note ASAB, gender identity, gender affirming treatments or surgeries |
Adapted from Raney J, Pal R, Lee T, et al.
Resources & references
Raney J, Pal R, Lee T, et al. Words matter: an antibias workshop for health care professionals to reduce stigmatizing language. MedEdPORTAL.2021;17:11115.