This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up. 1) The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number. 2) ): This is the historical part of the note. It contains the following: a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts). b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts). c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner. 3) Vital signs need to be present. Height and Weight should be included where appropriate. a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts). b)      Pertinent positives and negatives must be documented for each relevant system. c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts). 4) Diagnoses should be clearly listed and worded appropriately. 5) Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections. 6) Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified. 7) Is it literate, organized and complete?

In order to ensure a comprehensive review of patient write-ups, this sheet provides guidance on what aspects should be included and what our margin remarks might be about. The purpose of this guide is to maintain uniformity and to ensure all necessary information is covered in each write-up. The following elements should be included in every write-up:

1) Opening List of the Note: This section should include the patient’s age, sex, race, and marital status. The patient’s complaint should be presented in quotes. If the patient has multiple complaints, each complaint should be listed separately with a corresponding number, and each should be addressed in the subjective section under the appropriate number.

2) Historical Part of the Note: This section focuses on the patient’s history and includes the following components:

a) Symptom Analysis/HPI (History of Present Illness): This subsection should provide detailed information about the location, quality, quantity or severity, timing, setting, and factors that make the symptoms better or worse. Additionally, associated manifestations should be described. This section carries a weightage of 10 points.

b) Review of Systems: All associated systems should be reviewed, reporting any pertinent positives and negatives. This helps in identifying any other symptoms or issues related to the patient’s complaint. This section is also worth 10 points.

c) Relevant Medical History: This subsection should include any pertinent past medical history, family history, social history, allergies, and medications related to the complaint or problem. If there are multiple chief complaints, each should be addressed in this manner.

3) Vital Signs: This section should include the patient’s vital signs such as blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation. Additionally, height and weight should be included when appropriate.

a) Systems Examination: The write-up should include an examination of the appropriate systems that are consistent with those identified in the review of systems. This carries a weightage of 10 points.

b) Documentation of Pertinent Positives and Negatives: For each relevant system, it is important to document any pertinent positives (abnormal findings) and negatives (normal findings).

c) Description of Abnormalities: Any abnormalities should be fully described, including the measurement and recording of sizes when applicable. Descriptive terms such as “ok,” “clear,” “within normal limits,” positive/negative, and normal/abnormal should be avoided. This component is worth 5 points.

4) Diagnoses: Clear and appropriate listing of diagnoses is essential. The write-up should clearly indicate the diagnoses related to the patient’s complaint or problem.

5) Treatment and Counseling: This section should include any teaching, health maintenance, counseling, as well as pharmacological and non-pharmacological measures. If there are multiple diagnoses, it is helpful to divide this section into separate numbered subsections.

6) Differential Diagnosis Process: The note should demonstrate support for the appropriate differential diagnosis process. This means that there should be evidence of understanding which systems and symptoms are related to each complaint. The assessment/diagnoses should be consistent with the subjective section and the assessment and plan sections. The management should align with the identified assessment/diagnoses.

7) Literacy, Organization, and Completeness: The note should be well-written, organized, and complete. It should demonstrate clarity of thought and effective communication of the patient’s information.

By adhering to these guidelines, you can ensure that your write-ups are thorough, accurate, and meet the necessary criteria for a comprehensive patient assessment.