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1
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2
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3
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4
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Subjective:
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|
|
|
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History of present illness
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Chief complaint only
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1-3 elements identified
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> 4 elements identified
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4 elements + >3 chronic or inactive conditions identified.
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Review of Systems
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None
Items not pertinent to problem identified
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Pertinent to problem 1 system with pertinent positives and negatives.
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Pertinent to problem 2-9 systems, with pertinent positives and negatives
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> 10 pertinent systems identified, with pertinent positives and negatives.
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Past family and social history
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None
Inappropriate items noted.
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None appropriate to complaint
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One appropriate to history itentified
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>3 appropriate to history identified.
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Objective
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Physical Exam
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Problem focused.
1-5 bullet points in system exam.
Inappropriate system examined.
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Expanded problem focused 6-11 bullets
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Detailed 12 bullets
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Comprehensive exam. 9 body systems with 2 bullets in each system.
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Decision Making
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1 self limiting or minor problem
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Multiple systems; interpretation of minor lab required
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Multiple systems; review of >2 diagnostic studies required.
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Multiple systems; complex patient; >2 diagnostic studies interpreted; >2 future studies planned.
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Assessment
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|
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Assessment
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0= long narrative, not specific diagnosis.
1=Self limited minor.
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Established problem; stable or improved. Appropriate to history and assessment findings
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New problem; no additional work up planned
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New problem, additional work up planned.
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Plan
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Plan
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Inappropriate therapy.
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Appropriate pharmacological (dose& frequency) and nonpharmacological therapies
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Appropriate documentation of futher diagnostic studies; pharmacologic and non pharmacologic; anticipatory guidance regarding health promotion and disease prevention; appropriately notes instructions for RTC/Follow up
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Also includes appropriate referral consultation of complex patient.
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>22 = Exceptional; >21 points= A; >20 points = A-; >19 points = B+; >18 points = B