Workup
Also called Work-up, Clinical workup
A workup is the process of assessing a patient's problem: gathering sources, taking the history, examining, investigating and writing the assessment.
Why it matters in a workup
The workup ends in a written assessment and plan. Much of the information already exists in letters and results, so gathering it comes first.
A thorough workup that is badly written down helps nobody. The document is what the next clinician acts on.
Put it into practice
- Gather existing sources before writing
- Record the history in a fixed order
- End with a ranked differential and a plan with owners
Frequently asked questions
Is a workup the same as an assessment?
The workup is the process. The assessment is the document that records it.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- Presenting complaintThe presenting complaint is the main problem that brought the patient in, recorded in a short phrase and ideally in the patient's own words.
- Differential diagnosisA differential diagnosis is a ranked list of the conditions that could explain a patient's problem, with the reasoning for each position.
- Source documentA source document is the original record a fact comes from, such as a lab report, an ECG report or a letter. Checking it is how you verify a statement.