Phase II Clinical Skills Examination

Calibrated Peer Review Clinical Note Writing Tools

http://cpr.molsci.ucla.edu/cpr/cpr/login.asp

Username: ___________________

HTML Tag Inserts a line break (hard return). This is the equivalent of the Enter key. Abbreviations Common medical abbreviations are acceptable. HISTORY: Include significant positives and negatives from history of present illness, past medical history, review of system(s), social history, and family history.

PHYSICAL EXAMINATION: Include vital signs, general patient description, and indicate pertinent positive and negative findings related to presenting issue.

ASSESSMENT Synthetic Statement: Briefly summarize the patient’s presentation using semantic qualifiers. Differential Diagnosis: In order of likelihood, write no more than 5 differential diagnoses for this patient’s current problems. 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________ DIAGNOSTIC WORK UP: Immediate plans for no more than 5 further diagnostic studies. [If no results were supplied for invasive physical examination maneuvers (pelvic exam, rectal exam, etc.), these should be listed in the plan.] 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________

©2005 University of New Mexico School of Medicine, Assessment & Learning Programs Revised 06/05/2007