Information
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INSTRUCTIONS:
Complete this template as you would complete the clinical write-up in On Doctoring. To type in each category, simply click in the box to type. The record is divided into three segments:
Information
I. Interview
II. Physical Exam
III. Problem List, Assessment & Plan
To move throughout these segments, simply click on the bottom button "Next". The work will automatically save itself as you go.
Once you have reviewed and corrected all information, please export the template by clicking "Export" on the last page, and clicking "Send", which will open up your email. Send this PDF to your small group facilitator(s) when you have finished. Late submissions will not be accepted. Your facilitator will grade the write-up using the rubric on Blackboard. -
Student Name
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Patient Name
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Conducted on
Interview
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Chief complaint (Cc):
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HPI: OLDCARTS:
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ROS:
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PMH:
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Adult Illnesses:
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Psychiatric Hx:
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Surgeries/Procedures:
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Medications:
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Allergies/Adverse drug reactions:
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Social Hx:
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Habits: Tobacco Hx, Alcohol Hx, Drugs (illicit drug use), Exercise, Diet
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Preventative Health: Immunizations, Cholesterol, Colo-rectal cancer screening, advance directives, occupational exposures, injury prevention
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Sexual Hx: GYN/OB:
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Family Hx:
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Continue to next page.
Physical Exam
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Pt Description:
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Vital Signs: Laboratory & X-Ray findings:
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Physical Exam Findings:
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Continue to next page.
PL, A & P
PROBLEM LIST & SUMMARY STATEMENT
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Problem List:
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Summary Statement:
ASSESSMENT
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Most likely Dx (include reasoning):
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Alternative Dx considerations:
PLAN
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Diagnostics, Treatment, Patient education, Health promotion, F/U plans & Coordination of care
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Patient Reflection:
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PLEASE REVIEW ALL INFORMATION PRIOR TO SUBMISSION.
To submit, select "Export" and then "Send" to your facilitators' email(s).
