Vital Components: A Checklist

The students will format their write-ups based on the vital components of the history and physical examination template as described in the following. They can check off elements as they organize their write-ups.

Chief Complaint

12 sentences that clearly states the chief complaint in the patient's own words and is appropriately detailed (may use as the introduction to the patient)

History of Present Illness

Tells a chronologic and organized history that begins at baseline
Appropriate use of the 8 cardinal descriptors of each symptom
  • Timing
  • Location
  • Character
  • Aggravating Factors
  • Alleviating Factors
  • Associated Symptoms
  • Severity
  • Setting
Appropriately includes pertinent positives and negatives
Explores CC in a way that reveals students working Ddx
Appropriately incorporates other aspects of history into HPI (i.e. PMH/SH/FH)

Past Medical History/Past Surgical History

Appropriately detailed and prioritized including OB/Gyn and Psych
  • Onset and course
  • Symptoms
  • Complications and treatment
Includes appropriate health maintenance, OB/Gyn history and/or psychiatric history

Allergies/Medications

Appropriate detail to allergies (nature of adverse reaction)
Proper detail to med list (dose, route, freq). All medications are accounted for by problem in HPI/PMH.

Social History

Explores unhealthy as well as healthy habits with sufficient detail
Explores other psychosocial aspects pertinent to clinical scenario

Family History

Appropriately explores medical histories of family members

Review of Systems

Appropriately explores for co-morbid problems considering the particular patient:
  • Constitutional
  • Eyes
  • Ears Nose Mouth Throat
  • Cardio-vascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Integument
  • Musculoskeletal
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematology/Lymphatic
  • Allergy/Immunology

Exam

Physical exam explores Ddx adequately
Provides adequately detailed description of patient (could be pick out of line-up)
Exam organized in logical manner with appropriate number and use of body systems/areas
  • Constitutional (Vitals and General appearance)
  • Eyes
  • Ears Nose Mouth Throat
  • Head and Neck
  • Cardio-vascular
  • Respiratory
  • Chest (breasts)
  • Gastrointestinal
  • Genitourinary
  • Integument
  • Lymphatic
  • Musculoskeletal
  • Neurological
  • Psychiatric
Labs/medical test/imaging that is appropriate and sufficiently detailed

Summary Statement/Problem List

Summary succinctly and appropriately pulls together the major points
Problem list appropriately detailed (all problems listed)

Discussion/Plan

Discusses appropriately prioritized Ddx for all undiagnosed problems displaying sound medical decision making
Discusses medical decision making for all problems with appropriate level of detail
Explicitly describes treatment and /or diagnostic plan for each problem with appropriate level of detail including patient education and counseling
Appropriately incorporates references

Entire History and Physical Write-up

Written in a readable manner with proper grammar and spelling
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