Subjective: ID, CC, HPI, PMH/SH|, ROS 8 points All pieces present and adequately
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Subjective: ID, CC, HPI, PMH/SH|, ROS
All pieces present and adequately documented. The HPI and ROS was pertinent to the complaint. PMH was clear and pertinent to the complaint.
Information was clear and concise, not superfluous. 6 points
Most pieces adequately documented. The HPI and ROS were mostly pertinent to the complaint.
Information was mostly clear, with only slight amount of info. Missing or too much information included.
Missing part of the subjective component, or done incorrectly.
HPI missed some of the OLDCART elements.
ROS was confused with physical exam or was not pertinent to complaint. PMH missing half or more elements.
Severe deficits in subjective information. Very limited or no HPI or very limited or no ROS.
Past medical history missing key elements.
Objective: VS & PE
Student wrote VS and physical exam findings in an organized, thorough, and succinct summary. Physical exam for the particular week’s body system was elaborated upon.
Student included only pertinent systems besides the weekly focus exam.
Student wrote VS and physical exam findings in an organized, thorough, and succinct summary. Physical exam for the particular week’s body system was lacking detail.
Student included either too little information on other systems, or performed too many systems, similar to well or annual exam.
Physical exam findings were disorganized and difficult to read. The particular body system for weekly focused was inadequately described or missing.
Student did not include other body systems that were pertinent to the complaint.
Severe deficits in documentation of the physical exam findings.
Student did include other systems besides weekly system in the write-up.
Assessment with DDX and Plan
DDX contained at least 3 different, pertinent diagnoses considered for the scenario.
Student briefly listed why diagnoses were excluded
Final assessment/ Dx was clear, and reasonable (might not be 100% correct).
Plan included all elements listed, and reasonable for a beginner practitioner, even if not 100% correct.
DDX contained at least 3 different, pertinent diagnoses considered for the scenario, but student did not include why dx were ruled out.
Final assessment/ Dx clear, even if not correct.
Plan includes most elements listed, even if not all correct.
DDX was limited or not included. No rationale for why dx was excluded.
The plan was missing elements or was not in line with the chief complaint and physical findings. 4 points
The assessment and plan was missing or lacking major components. Lacked a DDX and the plan was missing major elements. / 10
The chosen format was neat and easy to read. Headings were clear. APA format was correct.
The format was mostly easy to read and understand, some elements of APA format is missing.
The format was inconsistent, headings and different areas were not delineated. No APA format.
Very poor format, note was confusing to read, no APA format.