Guides

Gather and document what a good patient workup needs

A good workup answers four questions in writing. What is the problem, what do the existing sources already say, what are the likely explanations, and what happens next. Most of the information already exists in the referral, earlier letters and results. The work is gathering it in one place and writing it down in an order a colleague can follow.

The Workup Desk team. Last reviewed November 3, 2026. General guidance on clinical documentation, not medical advice about any individual patient.

Answer four questions in every workup

Every assessment, referral letter and handover is an answer to the same four questions. You answer them in a different length for each document, but you answer them in the same order.

When one of them is missing, the reader has to reconstruct it. A letter with a plan and no reasoning invites a repeat workup. A letter with reasoning and no plan leaves the next doctor guessing who acts.

What is the problem? The presenting complaint in the patient's words, with its timeline.
What do the sources already say? Earlier letters, results, imaging, ECGs and the medication list.
What could explain it? A ranked differential with the working diagnosis named first.
What happens next? Investigations, referrals, safety-netting advice and who does each one.

Gather the sources before you write

You write a faster and safer assessment when the sources are in front of you before the visit note starts. A referral often omits the result that changes the picture, and that result is usually somewhere in the record already.

Collect them in one place per patient and note the date of each. A troponin from last week and one from last year answer different questions.

The sources worth gathering and what each one adds
Source	What it adds	What to check
Referral or request	The question being asked and by whom	Whether the question is explicit or has to be inferred
Previous letters	Diagnoses already made and plans already tried	Dates, and whether a plan was completed or dropped
Laboratory results	Trends as well as single values	Units, reference ranges and the date of each sample
Imaging and ECG reports	The reporter's findings and conclusion	Whether the report answers the clinical question asked
Medication list	Current drugs, doses and recent changes	Whether the list matches what the patient actually takes
Your visit notes	History and examination from today	That findings and interpretation are written separately

Take the history in a fixed order

A fixed order makes omissions visible. When every assessment starts with the presenting complaint and ends with the social history, a missing allergy line stands out to you and to the reader.

Write the history of presenting complaint as a timeline. Onset, character, triggers, relieving factors, associated symptoms and what has already been tried all belong there, in the order they happened.

Presenting complaint, in a short phrase.
History of presenting complaint, as a timeline.
Past medical history, with dates where they matter.
Medications and allergies, with the reaction for each allergy.
Family history relevant to the complaint.
Social history, including smoking with pack-years, alcohol, occupation and function.
Review of systems for the systems the complaint touches.

Keep findings apart from interpretation

A finding is what you observed or measured. An interpretation is what you think it means. Write them in separate sections so a reader can disagree with your interpretation without doubting your findings.

Record a normal result as a finding as well. A normal ECG and a normal troponin are evidence, and they shape the differential as much as an abnormal one.

Record what you did not find when it matters. The absence of a red flag you asked about is part of the assessment, and a later reader needs to know you asked.

Rank the differential and name the working diagnosis

A list of possibilities is only useful in order. Put the most likely explanation first and the most dangerous explanations you have not excluded next to it, with a line on why each is more or less likely.

Name a working diagnosis when you have one, and say how confident you are. A working diagnosis tells the next doctor what you are treating as true until a result says otherwise.

Write the plan so someone else can carry it out

The plan is the part of the assessment another person acts on. Write each item with an owner and a time frame, so the reader knows which tests are already requested and which are theirs to order.

Include the safety-netting advice you gave the patient. What symptoms should bring them back, how quickly, and to whom are part of the plan and part of the record.

Investigations requested, and who follows up the results.
Referrals made, with the question each one asks.
Medication changes, recorded as the decision you made.
Safety-netting advice given, in the words you used.
Follow-up, with a date or an interval.

Keep the source behind every statement

A workup built from several documents is only as reliable as your ability to check where each fact came from. When a letter says LDL 159 mg/dL, a reader should be able to find the result and its date.

This matters more when you draft with an AI tool. Ask for answers that name the source document, and check each statement against that source before it goes into the record. You stay responsible for the whole document.

Document these for every patient

A workup earns its place in the record when a colleague can act on it without asking you a question. That comes down to a short list.

The question you were asked, and by whom.
The sources you reviewed, with their dates.
The history in a fixed order, with red flags asked about.
Examination and investigation findings, kept apart from interpretation.
A ranked differential with the working diagnosis named.
A plan with owners, time frames and safety-netting advice.

Questions to check in your own work

1.Is the question I was asked written at the top of the assessment?
2.Have I reviewed the previous letters and results, and noted their dates?
3.Are findings and interpretation in separate sections?
4.Does the differential put the most likely and the most dangerous explanations first?
5.Does every plan item have an owner and a time frame?
6.Did I record the safety-netting advice I gave?

The guides, by subject

5 guides covering the workup above in detail. Each one explains what a document or a step contains, how doctors usually approach it, and what to check in your own work.

Clinical documents

Learn what an assessment and a referral letter contain, and in what order.

Clinical reasoning

Get from the history and findings to a ranked list of possibilities.

Building a differential diagnosisBuild a ranked differential from the history and findings, and write the reasoning down.

AI tools and patient data

See what general AI tools do well for doctors, and what to check before patient data goes in.

Common questions

What is the difference between a workup and an assessment?

The workup is the whole process of gathering sources, taking the history, examining and investigating. The assessment is the written document that records it and states your conclusion and plan.

Should I record normal results?

Yes, when they bear on the question. A normal result narrows the differential, and a reader who cannot see it may repeat the test.

Can an AI tool write the assessment for me?

An AI tool can draft from the sources you give it. You still check every statement against its source, edit the draft and make every clinical decision. The signed assessment is yours.

Is this medical advice?

No. These guides describe how clinical documents are commonly structured and what to gather for them. They do not give advice about any individual patient and they do not replace local guidelines or clinical judgment.

Try it on one patient's documents

Open a workspace for one patient, add the referral, letters and results, and draft the assessment from them. Early access is by invitation.