0 pts
70 pts
90 pts
100 pts
1. Introduces self 2. Identifies patient 3. Washes Hands 4. Determines existence of allergies, medications, herbal preps, etc
1. Obtains the Chief Complaine 2. Asks the appropriate questions related to the the CC and expands the HPI 3. Gathers pertinent past medical history, ROS, Family, Psychosocial 4. Performs Physical Exam Using the appropriate techniques of a. Inspection b. Palpation c. Percussion d. Auscultation
Report should have following components: SUBJECTIVE 1. Biographical Sketch 2. Chief complaint or reason for visit 3. Patient Hx using initals and no identifying number 4. Previous illnesses and/or surgeries 5. Narrative Review of System OBJECTIVE 1. Results of physical exam. 2. Any followup action plan or tests
Effective professional communication orally and in writing.