Fictional chart assignment (FCA) 1

Write a single fictional chart note for the following hypothetical patient. Some basic data are provided; the rest of the clinical details are up to you to invent. In other words, you make up a patient in your mind, make up what they have that would explain the symptoms below, then write the note that would support this diagnosis. Write a thorough (this does not automatically mean long) note that would convey the exact nature of the problem to a reader who had not witnessed the encounter. Include all subjective and objective data that you think are pertinent, but nothing that is not. Persuade me that your fictional patient really has what you say she has. For the plan, include everything that you would do for this patient if he/she was really in your office, including diagnostic steps, therapeutic steps, advice for follow-up, and patient education.

You can make it as simple or as exotic as you want. For example, if you want to make your patient have inhalational anthrax, go right ahead. But you'll need to convince me that she has it, so you better make her dad a postal worker.

Exotic does not mean long. Nor does simple mean short. Length doesn't matter, and making your note longer won't make it better. What matters is maximum information density.

Write a chart note, specific to this patient. Do not write a term-paperish general essay on the problems or diagnoses. If you wouldn't write it in a patient's chart, then don't write it in this assignment.

Submit your work via Blackboard.

Don't spend time making it look all nice and pretty; I'm interested in the content of your thoughts, not the appearance of your writing on the "electronic page."

There is no required minimum or maximum length. However, keep in mind that this is a chart note, not a term paper expounding on the clinical entity at hand. It is one note from one office visit. So in general terms, if you are spilling onto a second page, you are getting too long.

Here is your case:

An eight year old girl presents with her father, with complaints of sore throat, fever, nasal congestion, and cough.

There is nothing that happens among humans that is not instigated, negotiated, clarified, or mystified by language, including our attempts to acquire knowledge. . . . Knowledge of a subject mostly means knowledge of the language of that subject.

-Neil Postman