Internal Medicine

The Written Report

Documentation Following Grand Rounds and Clinical SeminarsPurpose

Each registrar who presents at Grand Rounds or the Clinical Seminars is required to produce a written record of the presentation. The purpose of this is as follows:

1. To deepen the learning value of the presentation for the registrar by encouraging further engagement with the subject material.

2. To provide practice in the summarising of material and in the writing and submission of reports.

3. To provide a written record which may be used for assessment.

4. To provide a permanent record as a learning material for colleagues within the Division, since all reports of an acceptable standard will be published on our web site.


1. The report will be self-standing. In other words, a reader who was not present at the oral presentation should be able to derive benefit from reading it.

2. The report will be a fluent, written document, submitted as a Word document. It will not include any part of the PowerPoint presentation, other than diagrams or images incorporated into the text in an appropriate fashion.

3. The report will be written to be educational and instructive. The lessons to be learnt from the case will emerge clearly and forcefully. It should be written such that it constitutes a valuable learning resource for other registrars preparing for examinations.

4. The report will include insights, corrections and new angles which emerged from the discussion. It is suggested that the presenting registrar asks a friend to take notes of comments made during the presentation and assists the registrar in incorporating them into the report.


The rules regarding plagiarism and self-plagiarism apply. This means that cut-and-paste, even of one’s own work in the PowerPoint, is unacceptable, as is copying and pasting of information from other sources. Where such information is used, it must be paraphrased in your own words and referenced.


Approximately 2 typed A4 pages.


The complete report plus appendices is to be received by the Friday of the following week. Thereafter it will be reviewed by a senior consultant or the HOD, and returned for revision of necessary with a one-week deadline. Once accepted, the report will be published on the web site and may be added to your portfolio. Particularly valuable reports will be considered for submission to a journal, and the registrar will be assisted with preparation of the manuscript in consultation with the consultant under whose auspices the original presentation was made.

Late submission at any stage will result in a stopped clock for the registrar’s training time.


The report is to be submitted in the following format:

Title data

1. Title

2. Diagnosis

3. Presenter

4. Date


The abstract should not exceed about 5 sentences. It should summarise the patient or patients and provide the most salient conclusions drawn from the discussion.

Case report

This will include only the most essential information about the patient. Only include the most relevant findings—positive and negative—and laboratory results. As a rule, absolute values should only be given for those results critical to an understanding of the case: for peripheral abnormalities, a verbal description is sufficient, e.g., in a patient whose problem is primary hyperparathyroidism, you might say: “The serum calcium peaked at 3.9 mmol/l (NR 2.1-2.6); urea and creatinine were moderately elevated.”


Summarise the background information relevant to an understanding of the case and identify the learning message which emerges from it. Under no circumstances is this to be a regurgitation of textbook material about a particular disease. It must represent your own interpretation of the knowledge and insights most relevant to your patient.


Summarise the take-home message in 1-2 sentences.


Append as few references as necessary, in Vancouver format.

Submission Format

Your report will be transferred to the web site. This requires reformatting using html, and is greatly simplified if the report is submitted as plain text. Therefore:

1. Use a single font of uniform size

2. No bold, italics or underlines

3. Avoid tables as far as possible

4. Do not distinguish headings in any way. Place them at the left of the page with a blank line before and after.

5. Append images, as JPG or GIF files, separately, not in the text. Provide a caption for each image.

6. If you can obtain the most useful papers you consulted as PDF documents, append these as well and we will make them available on the web.

7. Submit the report on a memory stick to Ms Hlongwa or by email attachment to