0 pts
1 pts
2 pts
3 pts
(N/A)
Includes all pertinent objective data
4 pts
6 pts
Provides clearly written explanation for patient appointment
Includes comprehensive subjective data
Includes comprehensive health history data
Includes comphrehensive lifestyle data
Lists learning needs based on health history and identified needs. Prioritizes list.
12 pts
17 pts
Assess all systems appropriately using inspection, palpation and auscultation as indicated. Appropriately assess all negative findings. Document all findings concisely using appropriate terminology.