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UST FACULTY OF MEDICINE & SURGERY

Department of Medicine

Medicine II
The Patient Write-Up_Grading Rubric

(Clinical History, Case Discussion and Master Problem List; August 2015)

Name of Student (Initials only) ___________________ Subsection ____


____________

Date

Med II Blocks:
( ) # 1/4: GI_Infectious Dse_Hematology_Oncology_Rheumatology
FACILITATOR: _____________________
( ) # 2/3: Cardiology_Pulmonology_Nephrology_Endocrinology
FACILITATOR:
_____________________

Original manuscript

1ST Revision

2nd Revision

HISTORY TAKING
(25 points)

1. General Data/Patient Information:

(Should contain ALL information listed below) (3)

Name (initials only):


Age:
Gender:
Birthday/Birthplace:
Nationality/Citizenship:
Educational attainment:
Civil Status:
Occupation:
Home Address:
Provincial address:
Contact number:
Informant/s (relationship to patient/Reliability):
Date admitted in USTH:
Date of Interview:

Religion:

2. Chief Complaint/s: (State patients main complaint or concern in his/her own words eg. Pilipino; Enclose in parenthesis the correct and appropriate
English translation.) (2)

3. History of Present Illness (HPI): (Make a thorough and organized HPI. Write in chronological order; Describe symptoms according to onset,
location, duration, character, aggravating or associated factors, relieving factors, temporal factors and severity; Note the pertinent negatives and positives.) (8)

4. Past (Medical) History: (Make a thorough and organized past medical history using a bullet-format Record previous childhood and adult medical
and surgical illnesses and hospitalizations; injuries/ accidents; obstetric/ gynecologic history ie. family planning method used if relevant to the diagnosis; Immunizations;
allergies --if none, write No known drug allergies; List medications -include generics/supplements & adverse drug reactions; Include current health status/risk factors ie.
nutrition, sleep, exercise, smoking, alcohol, illicit drug use); Use only standard and commonly accepted abbreviations.) (5)

5. Family History:

(List the common genetic disorders and major health conditions in the patients family - identify specific family members; include Medical
Genogram or Family Diagram ie. 3 - 4 generations) (2)

6. Personal/Social History:

(Briefly describe the cultural background, family structure & relationships, marital status, stress factors, educational
data, economic status; environmental data; occupational/ employment history; sexual history); Elaborate on the social history (*see NEJM Oct 2, 2014 issue for reference) (2)

7. Review of Systems: (Review and list ALL symptoms pertinent to the working diagnosis but were not accounted for in the HPI. Do not repeat any data
already mentioned in the HPI); Do not include PE findings or diagnosis in the ROS.) (3)

EVALUATION
OF HISTORY
TAKING
25 points

II. PHYSICAL
EXAMINATION
(25 points)

1. General Survey:

Page | 1

25 --- 20

19 -- 15

14 --- 10 ------------------- 0

Able to identify and discriminate


important historical information. Made
an organized, thorough, and complete
history.

Described important clinical data


pertaining to chief complaint
although incomplete. Noted
some discordant clinical
information.

Incomplete history; Recorded


history but unable to obtain
important clinical data relating
to chief complaint/Organsystem

__ No need to
Rewrite history
__ Rewrite & take
note of corrections

__________ Date of Admission (Current hospital confinement at USTH-CD)


__________ Date (*current) this physical exam was performed by the medical student
NOTE: Ideally, the PE findings to be recorded here should include both data on ADMISSION date and the *current
date for purposes of case discussion by the student
(Make a complete and accurate general survey; Describe the appropriate and relevant findings.) (1-2)

ivillespin/lanzona 8-26-15

UST FACULTY OF MEDICINE & SURGERY


Department of Medicine

Medicine II
The Patient Write-Up_Grading Rubric

(Clinical History, Case Discussion and Master Problem List; August 2015)

2. Vital Signs:

(Record the current vital signs including anthropometric data eg. BMI) (1-2)

3. Skin: (Describe the relevant findings adequately and include images of lesions -obtain patients consent; State pertinent negatives) (1-2)
4. HEENT/Neck:

(Describe and illustrate the appropriate findings adequately; include thyroid and fundoscopic findings if relevant) (1-2)

5. Thorax/Breast/Lungs:

*Lung Auscultogram:

(Describe and illustrate the appropriate findings adequately. Report pertinent negatives). (1-3)

(Illustrate the pertinent I P P A lung findings using the UST-CRM auscultogram) (1-2)

6. Cardiovascular: (Describe the appropriate findings adequately. Observe the correct sequence i.e. I - P - A. State pertinent negatives). (1-3)
*Heart Auscultogram:

7. Gastrointestinal:

(Draw the pertinent cardiovascular findings i.e. heart sounds, murmur - including the JVP, CAP and peripheral pulses) (1-2)

(Describe the relevant findings adequately; Note the correct sequence of abdominal exam ie. I-A-P-P; Include rectal if necessary;

State pertinent negatives) (1-3)

8. Musculoskeletal: (Describe the relevant findings adequately; Include MMT if necessary; State pertinent negatives) (1-2)
9. Extremities: (Describe the relevant findings adequately; State pertinent negatives) (1)
10. Neurological: (Describe the appropriate findings adequately; Note correct sequence of examination. State pertinent negatives) (1-2)
EVALUATION
OF PHYSICAL
EXAM
25 points

Page | 2

25 --- 20
Performed a complete and focused
PE.

19 -- 15
Lacks some important/relevant
PE findings.

14 --- 10 ------------------ 0
Performed an incomplete &
focused PE. Did not perform
some important / relevant PE
exam on the organ-system
involved.

__ No need to
Rewrite PE
__ Rewrite & take
note of corrections

ivillespin/lanzona 8-26-15

UST FACULTY OF MEDICINE & SURGERY


Department of Medicine

Medicine II
The Patient Write-Up_Grading Rubric

(Clinical History, Case Discussion and Master Problem List; August 2015)

CASE SUMMARY

(3-point bonus): Make a brief and organized narrative, which includes salient or pertinent information from the clinical history, physical
exam and baseline lab results, & imaging studies (when available) leading to the main diagnosis and key differentials.

III.

CASE DISCUSSION (Problem-Based)


(Total = 50 points)

A. PROBLEM
LIST
(5 points)

Note: Please use the Master Problem List (MPL) sheet. Read carefully the
DEFINITION OF A PROBLEM at the bottom of the MPL table. NOTE: The chief
complaint may be highlighted as a distinct problem statement in the MPL to
emphasize USTH patient-focused care.
Problem #1
Problem#2
Problem#3
54
Organized, thorough, and complete
MPL. Understood and applied correctly
the concepts used when stating a
PROBLEM as defined here. Higher
order thinking skills were evident
(Blooms)

B. DISCUSSION

32
Incomplete, disorganized and
too compartmentalized.
Problems included were based
only on hearsay. Applied lower
order thinking skills

1 0
MPL is grossly lacking;
Critical thinking/ clinical
reasoning was lacking.

__ No need to
rewrite
__ Rewrite & take
note of corrections

General Instruction: Discuss each problem in the MPL using the S-O-A-P
format, where:
S = Subjective findings/ Symptomatology i.e. a BRIEF historical narrative
pertinent/germane to the problem statement (Patient perspective)
O = Objective or physical examination findings (Doctor perspective)
A = Assessment or analysis of the S & O data; TO ENUMERATE at least 3
differentials and BRIEFLY explain your basis; to discuss its relationship (i.e.
association or correlation) with other problems in the MPL; to state the
disease prognosis using the most current literature
P = Plan of action for each problem in the MPL which includes: a) Diagnostic
b) Therapeutic c) Education/ Prevention

1. Diagnostics:
Diagnosis &
Differentials

2. Management:
Diagnostic Plan
(D) Treatment
Plan (T)
Education (E) &
Preventive
Measures
45 points:

Instruction: Discuss thoroughly the S O A P for each problem


(Note: Signs & symptoms may be repeated or rewritten in all enumerated
problems only if deemed relevant and contributory to the diagnosis and its
differentials)
Problem #1:
SOAP- (D/T/E)

(15 points per problem)

Problem#2:
SOAP- (D/T/E)
Problem#3:
SOA-

Page | 3

ivillespin/lanzona 8-26-15

UST FACULTY OF MEDICINE & SURGERY


Department of Medicine

Medicine II
The Patient Write-Up_Grading Rubric

(Clinical History, Case Discussion and Master Problem List; August 2015)

P- (D/T/E)
(Note: If more than 3 problems are being considered, PRIORITIZE your list (MPL)
according to the order of importance, severity and/or chronology of the problems
identified. ALWAYS BE CONSISTENT WHEN WRITING YOUR PROBLEM STATEMENTS IN
YOUR MPL & DISCUSSION

Rubrics for Diagnostics (S- O- A-)


8 76
Complete, organized, brief, and
included only the relevant
SUBJECTIVE & OBJECTIVE data that
are deemed contributory to EACH
problem and subsequently able to
make a correct, logical and complete
assessment including the prognosis.
Able to enumerate the differential
diagnosis (from the MOST to the
LEAST LIKELY) with brief discussion.

5 4 3
Lacking or included subjective
and/or objective data that are
irrelevant or noncontributory to
the problem. Explanation of S & O
data lack basis or logic;
Incomplete list of differentials;
Included diseases that logically
should not be considered;

2 10
Majority of the S & O data
included are irrelevant to
the problem. Unable to
make a logical
assessment/diagnosis
based on the S & O.
Minimal explanation done;
Lacking differentials

__ No need to
rewrite
__ Rewrite & take
note of corrections

Rubrics for Management Plans (P- )

C. Final
Disposition

7 65
Able to formulate an appropriate and
rational diagnostic & treatment
strategies focusing on plans that will:
a). Need utmost priority and should be
immediately done b). Confirm and
support the problem or address lifethreatening situations c). Provide the
evidence to rule out differentials
mentioned d). Address costcontainment schemes bearing in mind
financial resources of the patient.
Incorporated recent or up-to-date
guidelines and briefly cited relevant
journals in the discussion.

43
Able to formulate a satisfactory
diagnostic & treatment strategy
but is incomplete. Enumerated
plans included a) those that may
be delayed b) were requested
only for baseline purposes c) may
add financial burden to the
patient.

21 0
Diagnostic and treatment
strategies are incomplete
and minimal. Enumerated
plans included a) nonpriority or just alternatives to
support the problem b) offer
little benefit to the patient, or
c) costly procedures that will
cause unnecessary harm.
No guidelines or journals
cited.

Very good / Satisfactory clinical


history and case discussion. No need
to rewrite.

Rewrite only that part of the


clinical history or Case Discussion
with corrections and re-submit on
(Date) ________ together with the
initial manuscript.

Rewrite the entire


History & PE; and re-submit
on (Date) ____________
together with the initial
manuscript.

*This portion to be
filled up by your
facilitator

__ No need to
rewrite
__ Rewrite & take
note of corrections

SCORE:
I. History :
II. Physical

Exam:
III. Case

Discussion:

Total: _______

Submitted by / Signature over printed name / Date:


_____________________________________________________________
_____________
Students name:
(Last)
(First)
(Middle)
Date

Facilitator: ______________________________________
_____________

Date Received/Checked:

Signature over Printed Name

Page | 4

ivillespin/lanzona 8-26-15

UNIVERSITY OF SANTO TOMAS HOSPITAL


Espaa Blvd., Manila 1015
Tel Nos. 731-3001 to 29; http://www.usthospital.com.ph
DEPARTMENT OF MEDICAL EDUCATION AND RESEARCH

*NOTE: This form is for practice use only by medical students and is not an official hospital
document
Patie
nt
Nam
e
Date of

Last Name:
First Name:
Middle Name:
Admission:

Age:

Gender:
Male
Female

Ward:

Room/Bed No.

Hospital No.

Out Patient Services


Emergency Room
Date of 1st consultation at OPS
Private Division
______________________
Clinical Division
Chief Complaint/s or Chief Concern (Tagalog word or phrase/ English translation):
Date of MPL:
Problem
Number

MPL Revision Number:


PROBLEM LIST

(List your Problem Statements according to the order of importance,


(a permanently severity and/or chronology; Small alphabets may be used to designate
assigned number; attributes of a confirmed disease/disorder) eg. #1-DM a.) nephropathy
When revising the Note: The chief complaint or presenting problem is usually assigned to
MPL, the
Problem #1 - to emphasize and highlight our patient-focussed care
assigned no. is approach.
either retained or
retired not to be
re-used for new
problems

Date problem
was
noted/recogni
zed
(Date of appearance or
diagnosis of problem;
Date of intervention; May
use confinement date if
unknown or unsure )

Action Taken

Date

when upgrading this initial


proble
problem to a higher level of
m was
understanding
resolve
Example: see problem #
d
1- Cough & Dyspnea see #4
a. to a higher
2-Fever
see #4
level OR
3-lobar infiltrates (cxr) see #4 b. Date disease
4-PNEUMONIA
cured

NOTE: Please read this definition-guideline carefully before constructing your MPL.
WHAT IS A PROBLEM?
a. It may be a symptom; a group of symptoms; an abnormal PE finding; laboratory or imaging
results; a previously confirmed diagnosis; a pathology report; a treatment intervention or
surgical procedure
b. Any condition needing further diagnostic and/or treatment intervention and follow-up medical
or surgical care.
c. ALL problem statements must be supported by hard data.
d. No hearsay evidence is allowed.
e. AVOID writing in the Problem List column the following words/phrases: Possible or probably
ivillespin 8-25-15

UNIVERSITY OF SANTO TOMAS HOSPITAL


Espaa Blvd., Manila 1015
Tel Nos. 731-3001 to 29; http://www.usthospital.com.ph
DEPARTMENT OF MEDICAL EDUCATION AND RESEARCH
f.

due to; to consider (T/c); rule in (R/i); rule out (R/o); Secondary to; versus (vs) and question
mark (?)
Your differential diagnoses should be written in the assessment portion of the progress notes -NOT in the MPL form.

Prepared by:
3rd Year Medical
Student
Junior Intern/ PGI/
Resident
Validated by:
Attending
Physician/
Consultant/
Medicine II
Facilitator
Disposition:

______________________________________
Signature over Printed Name

Date:

______________________________________
Signature over Printed Name

Date:

______________________________________
Signature over Printed Name

Revise this MPL

Date:
No need to

revise

ivillespin 8-25-15