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2.6 Assignment (30 points)
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Criteria
Level 1
Criterion Score
Chief Complaint
1 point
A 1-2 sentence Chief Complaint is included.
Score of Chief Complaint,
/ 1
HPI
2 points
HPI is included and uses OLDCARTS format.
Score of HPI,
/ 2
Past Medical History
2 points
Past Medical History is included and covers previous diagnoses, surgeries, and hospitalizations.
Score of Past Medical History,
/ 2
Social History
2 points
Social History is included and covers living situation, job, alcohol, drugs, tobacco.
Score of Social History,
/ 2
Medications
1 point
Medication list included (name of drug, dose, and frequency). Must include a minimum of two drugs patient is currently on.
Score of Medications,
/ 1
Review of Systems
5 points
Review of Systems is included and contains subjective data pertinent to the patient’s reason for visit and symptoms.
Score of Review of Systems,
/ 5
Vitals
1 point
Vital Signs included.
Score of Vitals,
/ 1
Physical Exam
5 points
Physical Exam included and contains objective data pertinent to the patient’s reason for visit and symptoms.
Score of Physical Exam,
/ 5
Assessment
5 points
A differential diagnosis list is Included. You will need to list 3 top potential diagnoses (in order from most likely to least likely) and provide a rationale for why you included it and why or why not it is the most likely diagnosis. Each potential diagnosis must be supported by an evidence-based resource.
Score of Assessment,
/ 5
Plan
5 points
Plan is included and is supported by at least 1 evidence-based resource.
Score of Plan,
/ 5
References
1 point
Reference list is included and written in APA format.
Score of References,
/ 1
Total
Score of 2.6 Assignment (30 points),
/ 30
Overall Score
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