The HPI and ROS were mostly pertinent to the complaint.
Information was mostly clear, with only slight amount of info. Missing or too much information included.
4 points
Missing part of the subjective component, or done incorrectly.
HPI missed some of the OLDCART elements.
ROS was confused with physical exam or was not pertinent to complaint.
PMH missing half or more elements.
2 points
Severe deficits in subjective information.
Very limited or no HPI or very limited or no ROS.
Past medical history missing key elements.
/ 8
Objective: VS & PE
7 points
Student wrote VS and physical exam findings in an organized, thorough, and succinct summary.
Physical exam for the particular week’s body system was elaborated upon.
Student included only pertinent systems besides the weekly focus exam.
5 points
Student wrote VS and physical exam findings in an organized, thorough, and succinct summary.
Physical exam for the particular week’s body system was lacking detail.
Student included either too little information on other systems, or performed too many systems, similar to well
or annual exam.
3 points
Physical exam findings were disorganized and difficult to read.
The particular body system for weekly focused was inadequately described or missing.
Student did not include other body systems that were pertinent to the complaint.
1 point
Severe deficits in documentation of the physical exam findings.
Student did include other systems besides weekly system in the write-up.
/ 7
Assessment with DDX and Plan
10 points
DDX contained at least 3 different, pertinent diagnoses considered for the scenario.
Student briefly listed why diagnoses were excluded
Final assessment/ Dx was clear, and reasonable (might not be 100% correct).
Plan included all elements listed, and reasonable for a beginner practitioner, even if not 100% correct.
DDX contained at least 3 different, pertinent diagnoses considered for the scenario, but student did not include
why dx were ruled out.
Final assessment/ Dx clear, even if not correct.
Plan includes most elements listed, even if not all correct.
6 points
DDX was limited or not included. No rationale for why dx was excluded.
The plan was missing elements or was not in line with the chief complaint and physical
Sample Solution