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Department of Medicine
Medicine II
The Patient Write-Up_Grading Rubric
(Clinical History, Case Discussion and Master Problem List; August 2015)
Date
Med II Blocks:
( ) # 1/4: GI_Infectious Dse_Hematology_Oncology_Rheumatology
FACILITATOR: _____________________
( ) # 2/3: Cardiology_Pulmonology_Nephrology_Endocrinology
FACILITATOR:
_____________________
Original manuscript
1ST Revision
2nd Revision
HISTORY TAKING
(25 points)
Religion:
2. Chief Complaint/s: (State patients main complaint or concern in his/her own words eg. Pilipino; Enclose in parenthesis the correct and appropriate
English translation.) (2)
3. History of Present Illness (HPI): (Make a thorough and organized HPI. Write in chronological order; Describe symptoms according to onset,
location, duration, character, aggravating or associated factors, relieving factors, temporal factors and severity; Note the pertinent negatives and positives.) (8)
4. Past (Medical) History: (Make a thorough and organized past medical history using a bullet-format Record previous childhood and adult medical
and surgical illnesses and hospitalizations; injuries/ accidents; obstetric/ gynecologic history ie. family planning method used if relevant to the diagnosis; Immunizations;
allergies --if none, write No known drug allergies; List medications -include generics/supplements & adverse drug reactions; Include current health status/risk factors ie.
nutrition, sleep, exercise, smoking, alcohol, illicit drug use); Use only standard and commonly accepted abbreviations.) (5)
5. Family History:
(List the common genetic disorders and major health conditions in the patients family - identify specific family members; include Medical
Genogram or Family Diagram ie. 3 - 4 generations) (2)
6. Personal/Social History:
(Briefly describe the cultural background, family structure & relationships, marital status, stress factors, educational
data, economic status; environmental data; occupational/ employment history; sexual history); Elaborate on the social history (*see NEJM Oct 2, 2014 issue for reference) (2)
7. Review of Systems: (Review and list ALL symptoms pertinent to the working diagnosis but were not accounted for in the HPI. Do not repeat any data
already mentioned in the HPI); Do not include PE findings or diagnosis in the ROS.) (3)
EVALUATION
OF HISTORY
TAKING
25 points
II. PHYSICAL
EXAMINATION
(25 points)
1. General Survey:
Page | 1
25 --- 20
19 -- 15
14 --- 10 ------------------- 0
__ No need to
Rewrite history
__ Rewrite & take
note of corrections
ivillespin/lanzona 8-26-15
Medicine II
The Patient Write-Up_Grading Rubric
(Clinical History, Case Discussion and Master Problem List; August 2015)
2. Vital Signs:
(Record the current vital signs including anthropometric data eg. BMI) (1-2)
3. Skin: (Describe the relevant findings adequately and include images of lesions -obtain patients consent; State pertinent negatives) (1-2)
4. HEENT/Neck:
(Describe and illustrate the appropriate findings adequately; include thyroid and fundoscopic findings if relevant) (1-2)
5. Thorax/Breast/Lungs:
*Lung Auscultogram:
(Describe and illustrate the appropriate findings adequately. Report pertinent negatives). (1-3)
(Illustrate the pertinent I P P A lung findings using the UST-CRM auscultogram) (1-2)
6. Cardiovascular: (Describe the appropriate findings adequately. Observe the correct sequence i.e. I - P - A. State pertinent negatives). (1-3)
*Heart Auscultogram:
7. Gastrointestinal:
(Draw the pertinent cardiovascular findings i.e. heart sounds, murmur - including the JVP, CAP and peripheral pulses) (1-2)
(Describe the relevant findings adequately; Note the correct sequence of abdominal exam ie. I-A-P-P; Include rectal if necessary;
8. Musculoskeletal: (Describe the relevant findings adequately; Include MMT if necessary; State pertinent negatives) (1-2)
9. Extremities: (Describe the relevant findings adequately; State pertinent negatives) (1)
10. Neurological: (Describe the appropriate findings adequately; Note correct sequence of examination. State pertinent negatives) (1-2)
EVALUATION
OF PHYSICAL
EXAM
25 points
Page | 2
25 --- 20
Performed a complete and focused
PE.
19 -- 15
Lacks some important/relevant
PE findings.
14 --- 10 ------------------ 0
Performed an incomplete &
focused PE. Did not perform
some important / relevant PE
exam on the organ-system
involved.
__ No need to
Rewrite PE
__ Rewrite & take
note of corrections
ivillespin/lanzona 8-26-15
Medicine II
The Patient Write-Up_Grading Rubric
(Clinical History, Case Discussion and Master Problem List; August 2015)
CASE SUMMARY
(3-point bonus): Make a brief and organized narrative, which includes salient or pertinent information from the clinical history, physical
exam and baseline lab results, & imaging studies (when available) leading to the main diagnosis and key differentials.
III.
A. PROBLEM
LIST
(5 points)
Note: Please use the Master Problem List (MPL) sheet. Read carefully the
DEFINITION OF A PROBLEM at the bottom of the MPL table. NOTE: The chief
complaint may be highlighted as a distinct problem statement in the MPL to
emphasize USTH patient-focused care.
Problem #1
Problem#2
Problem#3
54
Organized, thorough, and complete
MPL. Understood and applied correctly
the concepts used when stating a
PROBLEM as defined here. Higher
order thinking skills were evident
(Blooms)
B. DISCUSSION
32
Incomplete, disorganized and
too compartmentalized.
Problems included were based
only on hearsay. Applied lower
order thinking skills
1 0
MPL is grossly lacking;
Critical thinking/ clinical
reasoning was lacking.
__ No need to
rewrite
__ Rewrite & take
note of corrections
General Instruction: Discuss each problem in the MPL using the S-O-A-P
format, where:
S = Subjective findings/ Symptomatology i.e. a BRIEF historical narrative
pertinent/germane to the problem statement (Patient perspective)
O = Objective or physical examination findings (Doctor perspective)
A = Assessment or analysis of the S & O data; TO ENUMERATE at least 3
differentials and BRIEFLY explain your basis; to discuss its relationship (i.e.
association or correlation) with other problems in the MPL; to state the
disease prognosis using the most current literature
P = Plan of action for each problem in the MPL which includes: a) Diagnostic
b) Therapeutic c) Education/ Prevention
1. Diagnostics:
Diagnosis &
Differentials
2. Management:
Diagnostic Plan
(D) Treatment
Plan (T)
Education (E) &
Preventive
Measures
45 points:
Problem#2:
SOAP- (D/T/E)
Problem#3:
SOA-
Page | 3
ivillespin/lanzona 8-26-15
Medicine II
The Patient Write-Up_Grading Rubric
(Clinical History, Case Discussion and Master Problem List; August 2015)
P- (D/T/E)
(Note: If more than 3 problems are being considered, PRIORITIZE your list (MPL)
according to the order of importance, severity and/or chronology of the problems
identified. ALWAYS BE CONSISTENT WHEN WRITING YOUR PROBLEM STATEMENTS IN
YOUR MPL & DISCUSSION
5 4 3
Lacking or included subjective
and/or objective data that are
irrelevant or noncontributory to
the problem. Explanation of S & O
data lack basis or logic;
Incomplete list of differentials;
Included diseases that logically
should not be considered;
2 10
Majority of the S & O data
included are irrelevant to
the problem. Unable to
make a logical
assessment/diagnosis
based on the S & O.
Minimal explanation done;
Lacking differentials
__ No need to
rewrite
__ Rewrite & take
note of corrections
C. Final
Disposition
7 65
Able to formulate an appropriate and
rational diagnostic & treatment
strategies focusing on plans that will:
a). Need utmost priority and should be
immediately done b). Confirm and
support the problem or address lifethreatening situations c). Provide the
evidence to rule out differentials
mentioned d). Address costcontainment schemes bearing in mind
financial resources of the patient.
Incorporated recent or up-to-date
guidelines and briefly cited relevant
journals in the discussion.
43
Able to formulate a satisfactory
diagnostic & treatment strategy
but is incomplete. Enumerated
plans included a) those that may
be delayed b) were requested
only for baseline purposes c) may
add financial burden to the
patient.
21 0
Diagnostic and treatment
strategies are incomplete
and minimal. Enumerated
plans included a) nonpriority or just alternatives to
support the problem b) offer
little benefit to the patient, or
c) costly procedures that will
cause unnecessary harm.
No guidelines or journals
cited.
*This portion to be
filled up by your
facilitator
__ No need to
rewrite
__ Rewrite & take
note of corrections
SCORE:
I. History :
II. Physical
Exam:
III. Case
Discussion:
Total: _______
Facilitator: ______________________________________
_____________
Date Received/Checked:
Page | 4
ivillespin/lanzona 8-26-15
*NOTE: This form is for practice use only by medical students and is not an official hospital
document
Patie
nt
Nam
e
Date of
Last Name:
First Name:
Middle Name:
Admission:
Age:
Gender:
Male
Female
Ward:
Room/Bed No.
Hospital No.
Date problem
was
noted/recogni
zed
(Date of appearance or
diagnosis of problem;
Date of intervention; May
use confinement date if
unknown or unsure )
Action Taken
Date
NOTE: Please read this definition-guideline carefully before constructing your MPL.
WHAT IS A PROBLEM?
a. It may be a symptom; a group of symptoms; an abnormal PE finding; laboratory or imaging
results; a previously confirmed diagnosis; a pathology report; a treatment intervention or
surgical procedure
b. Any condition needing further diagnostic and/or treatment intervention and follow-up medical
or surgical care.
c. ALL problem statements must be supported by hard data.
d. No hearsay evidence is allowed.
e. AVOID writing in the Problem List column the following words/phrases: Possible or probably
ivillespin 8-25-15
due to; to consider (T/c); rule in (R/i); rule out (R/o); Secondary to; versus (vs) and question
mark (?)
Your differential diagnoses should be written in the assessment portion of the progress notes -NOT in the MPL form.
Prepared by:
3rd Year Medical
Student
Junior Intern/ PGI/
Resident
Validated by:
Attending
Physician/
Consultant/
Medicine II
Facilitator
Disposition:
______________________________________
Signature over Printed Name
Date:
______________________________________
Signature over Printed Name
Date:
______________________________________
Signature over Printed Name
Date:
No need to
revise
ivillespin 8-25-15