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Evaluation Criteria for Patient Write-ups

These are the descriptive anchors used by your portfolio advisors to help evaluate your portfolio. Not all will exactly fit your write-ups so they may be skipped or clarfied in the comments.

CC

  • Missing
  • Unclear or buried in extraneous information
  • Clearly and concisely stated

HPI

  • Organization very confusing and/or critical information missing (i.e. 7 dimensions of a cardinal symptom)
  • Organization generally clear and critical information is present but some details missing
  • Well-organized, critical information and pertinent related information included; there is evidence that the student has a rudimentary differential in mind

Other History – PMH, Meds, All, FHx, SHx, ROS

  • Parts missing without reasonable explanation
  • Everything is covered but missing key detail(s) (e.g. nature of allergic reactions)
  • Everything is covered but missing some detail(s) or overly redundant
  • Complete with appropriate details

Physical Examination

  • Missing relevant parts of the examination or provides inadequate descriptions (e.g. vitals missing or “neuro-normal”)
  • Complete exam with clear descriptors
  • Complete exam, clearly described with appropriate emphasis on aspects relevant to the CC

Data Collection -labs, x-rays, ECGs, etc.

  • Missing
  • Missing key information without explanation
  • Key information present and clearly documented

Differential Diagnosis -Integrated into the assessment

  • None provided
  • Minimal differential that misses some key considerations
  • Reasonable possibilities are addressed
  • Advanced for this level of training, student clearly did additional reading

Assessment

  • Student never clearly states an assessment/”working diagnosis” or substitutes a symptom or body system for a working diagnosis
  • Working diagnosis is present but unclear as buried in the differential or discussion
  • The working diagnosis is stated clearly with some rationale
  • The working diagnosis is stated clearly and it is clear that the student understands why (student is able to distinguish the key portions of data that are collected to synthesize them into an assessment)

Plan

  • Critical aspect (something that could lead to serious harm) in work up or management is missing (e.g. forgets heparin in patient with PE)
  • A reasonable beginning plan for work-up and/or management of the working diagnosis
  • Work-up/management plan addresses other problems in addition to “main problem”
  • Work-up/.management plan addresses all active problems and shows evidence of outside reading and understanding of pathophysiology (a thoughtful plan rather than a “shotgun” approach-both of which can be technically complete)

General/HIPAA 

PLEASE NOTE: HIPAA violations will have to be fixed and resubmitted. If it is discovered after the clerkship has ended, the submission cannot be revised and resubmitted. It will simply be removed by IT.

  • Violates HIPAA or significant redundancy or illegible
  • Overall organized according to standard template and avoids redundancy