|
Subject
|
-Criteria
|
Possible Points
|
|
Patient Demographics
|
-Gender, age, ethnicity, and other social demographics as indicated (self-pay, Insurance)
|
5
|
|
Chief Complaint
|
-Use the patient’s own words—one or more symptoms or concerns cause the patient to seek care.
-Elaborate on the chief complaint; describes how each symptom developed.
I-ncludes the patient’s thoughts and feelings about the illness.
|
5
|
|
History of Present Illness
|
-Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations)
-HPI narrative flows smoothly in a logical fashion
-For those who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS (
Onset,
Location/radiation,
Duration,
Character,
aggravating factors,
Relieving factors,
Timing and
Severity).
|
10
|
|
Past Medical History
|
-Lists childhood illnesses
-Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric.
-Medication, Allergies
-Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety.
|
5
|
|
Current Health Status
|
-Summary of general health status related to the present illness.
|
5
|
|
Family History
Narrative and Genogram
https://genopro.com/genogram/medical/Links to an external site.
|
-Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children.
-Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease)
-The family pedigree shows at least three generations and involves the use of standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification.
|
10
|
|
Risk assessment based on family history
|
-Family history of a known or suspected genetic condition
-Ethnic predisposition to certain genetic disorders
-Consanguinity (blood relationship of parents)
-Multiple affected family members with the same or related disorders
-Earlier than expected age of onset of disease
-Diagnosis in less-often-affected sex
|
10
|
|
Past Surgical History
|
-Were they ever operated on, even as a child?
-What year did this occur?
-Were there any complications?
|
5
|
|
Social History
|
-Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur?
-Do they drink alcohol? If so, how much per day and what type of drink?
-Any drug use, past or present, should be noted.
-Work, family, friends, community support systems,
|
5
|
|
Sexual Activity
|
-Do they participate in intercourse? With persons of the same or opposite sex?
-Are they involved in a stable relationship?
-Do they use condoms or other means of birth control?
-Married? The health of the spouse? Divorced? Past sexually transmitted diseases?
-Do they have children? If so, are they healthy? Do they live with the patient?
|
5
|
|
Work/Hobbies/Other
|
-What sort of work does the patient do?
-Have they always done the same thing? Do they enjoy it?
-If retired, what do they do to stay busy? Any hobbies?
|
5
|
|
Review of systems (ROS)
|
-Documentation of the presence or absence of common symptoms related to each major body system.
-Consider asking a series of questions going from “head to toe.”
-The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis)
-These disorders would only be recognized if the patient were explicitly prompted.
· Format
· General/skin/sleep
· HEENT
· Respiratory
· Cardiovascular
· Musculoskeletal
· Endocrine
· Gastrointestinal and Urinary
· Neuro/psyc
|
10
|
|
Prevention and Health Promotion
|
-At least one prevention activity.
-At least three health promotion recommendations.
|
10
|
|
APA Guidelines & Writing Style
|
APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.
|
10
|
|
Total
|
|
100
|
