Assignment Rubric: Patient Write-Ups
Introduction
Patient write-ups are an essential component of medical documentation and serve as a critical tool for effective communication among healthcare providers. This assignment rubric aims to provide guidance on the key elements that must be included in every write-up of patients. The rubric evaluates various aspects such as the opening list, historical information, vital signs, diagnoses, treatment plans, and overall organization and completeness. By adhering to these guidelines, students can ensure comprehensive and well-structured patient write-ups.
1) Opening List
The opening list in a patient write-up should include important demographic information such as age, sex, race, and marital status. Additionally, the patient’s complaint(s) should be clearly stated using verbatim quotes. If the patient presents with more than one complaint, each complaint should be listed separately with corresponding numbers for easy reference. Moreover, each complaint must be addressed in the subjective section under the appropriate number.
2) Historical Information
The historical part of the note focuses on gathering and documenting relevant information regarding the patient’s medical history. It consists of the following components:
a) Symptom Analysis/History of Present Illness (HPI):
The HPI should provide a comprehensive analysis of the patient’s symptoms, including the location, quality, quantity or severity, timing, setting, and factors that exacerbate or alleviate the symptoms. It is essential to mention any associated manifestations related to the complaint. A thorough and detailed description of the HPI is crucial for accurate diagnosis and management.
b) Review of Systems:
This section requires a systematic assessment of associated systems to identify pertinent positives and negatives. All relevant systems should be examined, and any abnormalities or notable findings must be reported. This comprehensive review enables healthcare providers to consider potential underlying conditions and develop an appropriate treatment plan.
c) Past Medical History, Family History, Social History, Allergies, and Medications:
In this part of the note, significant details related to the patient’s medical history, family history, social history, allergies, and medications relevant to the current complaint should be documented. It is vital to include relevant information that may help in determining the diagnosis and planning appropriate interventions.
If the patient has multiple chief complaints, each complaint should be addressed separately, following the same structure outlined above.
3) Vital Signs
The inclusion of vital signs is critical in patient write-ups as it provides important physiological data for healthcare providers. Vital signs such as blood pressure, heart rate, respiratory rate, and temperature must be recorded. In certain cases, height and weight may also be relevant and should be included. In addition to recording the vital signs, an examination of appropriate systems should be conducted and documented. This examination must align with the systems identified in the review of systems (2b). Furthermore, pertinent positives and negatives should be clearly documented for each relevant system. If any abnormalities are detected, they should be fully described, including measurements if applicable. Avoid using vague terms like “ok” or “clear” to describe findings; instead, provide specific and descriptive details.
4) Diagnoses
The section on diagnoses should clearly list the conditions identified based on the patient’s symptoms, medical history, and examination findings. The diagnoses should be worded appropriately, following standard medical terminology. If there are multiple diagnoses, it is beneficial to divide this section into separate numbered subsections for clarity and organization.
5) Treatment Plan
In this section, students should include any teaching, health maintenance, counseling, pharmacological measures, and non-pharmacological measures. The treatment plan should be comprehensive and tailored to each specific diagnosis. If there are multiple diagnoses, it is important to address each one separately in this section. Including an evidence-based rationale for the chosen treatment options is desirable.
6) Differential Diagnosis Process
The assessment and diagnosis should reflect a thorough understanding of the appropriate differential diagnosis process. There should be clear evidence that the student comprehends which systems and symptoms correlate with each complaint. The assessment/diagnoses should be consistent with the subjective section, as well as the assessment and plan. The management strategies should align with the identified assessment/diagnoses.
7) Literacy, Organization, and Completeness
The final aspect evaluated in this rubric is the overall literacy, organization, and completeness of the patient write-up. The note should reflect a high level of proficiency in medical terminology, grammar, and syntax. It should also demonstrate a logical and well-structured flow of information. Additionally, the note should be thorough and complete, addressing all the required components outlined in this rubric.
Conclusion
By paying careful attention to the elements outlined in this rubric, students can ensure comprehensive, accurate, and well-structured patient write-ups. Adhering to these guidelines will contribute to effective communication and promote a thorough understanding of the patient’s condition among healthcare providers. This rubric serves as a valuable tool for self-assessment and guidance in meeting the expectations of patient write-ups.
