Rationale

• To document the student's data collection and clinical reasoning process.
• To provide practice in essential written communication skills.
• To facilitate the student's self-directed learning by formalizing the process of identification and discussion of learning issues.

Evaluation Criteria

General

The write-up includes the date and time of the patient assessment

The write-up is signed.

The write-up is submitted electronically via disk or email to bswann@medicine.nodak.edu

Database

Patient is adequately identified.

Chief complaint or reason for admission is clearly stated in one sentence and includes the duration of the complaint.

HPI is chronological, includes appropriate positive and negative data, and includes information as to how the illness has impacted the patient's life.

Chronic-active problems listen in PMH include information (if available) on circumstances of diagnosis, previous management, and current status.

Current health status data includes allergies, current medications, health habits, immunization status, and results of screening tests.

Psycho-social history includes home circumstances, significant interpersonal relationships, and daily activities.

The patient's general appearance and vital signs are adequately described.

The remainder of the physical exam section describes all significant findings.

Significant laboratory and radiographic data are included if available.

Problem List/Assessment

The problem list is comprehensive (accounts for all significant abnormalities).

Problems are prioritized.

Problems are labeled as specifically as possible (to the highest degree of resolution), while avoiding premature diagnostic closure.

Plan of Action

The plan is problem based.

Emphasis is placed on the presenting or primary problem.