Description
Focused/Episodic Visit Note
Focused/Episodic Visit Note
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeName and DOB
5 pts
Full Marks
Verify patient’s name and DOB
2.5 pts
partial points
Includes one component only
0 pts
No Marks
Does not include both components
5 pts
This criterion is linked to a Learning OutcomeChief Concern or Chief Complaint (CC)
5 pts
Full Marks
CC – Clearly stated in appropriate format
2.5 pts
partial points
CC partially stated and/or not written in proper format
0 pts
No Marks
Does not include or does not clearly state CC
5 pts
This criterion is linked to a Learning OutcomeHistory of Present Illness (HPI)
20 to >15.0 pts
Full Marks
Includes all components necessary from the acronym OLDCART. Does not include term OLDCART or written out words of acronym. Includes full information to guide to diagnosis.
15 to >10.0 pts
partial points
Does not include all components necessary from the acronym OLDCART. Include term OLDCART or writes out words of acronym. Missing information to guide to diagnosis.
10 to >0 pts
partial points
Components not explained. Missing pertinent positives and negatives. Does not include information to guide to diagnosis.
20 pts
This criterion is linked to a Learning OutcomeMedications
4 pts
Full Marks
Include all 3 components including name, dose, frequency, reason Prescription (include medical cannabis and oral contraceptives) Non-prescription drugs or medications Vitamins, minerals, or herbal supplements/herbals
3 pts
partial points
Include only 2 components including name, dose, frequency, reason Prescription (include medical cannabis and oral contraceptives) Non-prescription drugs or medications Vitamins, minerals, or herbal supplements/herbals
2 pts
partial points
Includes only 1 component including name, dose, frequency, reason Prescription (include medical cannabis and oral contraceptives) Non-prescription drugs or medications Vitamins, minerals, or herbal supplements/herbals
4 pts
This criterion is linked to a Learning OutcomeAllergies
4 pts
Full Marks
Include reactions to medications, environment, food, latex
3 pts
partial points
Includes 2 -3: medications, food, allergy, latex and/or does not include reaction
1 pts
partial points
Includes 1: medications, food, allergy, latex and/or does not include reaction
4 pts
This criterion is linked to a Learning OutcomePersonal & Social History:
15 pts
Full Marks
Includes all information and components of social history that are pertinent to the CC. Always include: Tobacco – type, quantity, duration (pack/year) Alcohol – type, quantity, frequency Drug use (illicit substance) DO NOT include unless definitively leads to a diagnosis – points will be deducted for including all for no reason (see rubric) or not including a pertinent one. This is the key to this assignment. Exercise and Diet – type & frequency of exercise; usual daily foods, caffeinated products Living & home situation – significant others, sources of stress, alterations in ADL’s Safety – seat belts, helmets, sunblock, smoke detectors, medical alert devices, etc. Alterations in sleep pattern Religious or spiritual beliefs Occupational — current job or retirement, possible exposures, deployment Recent Travel (possible exposures, illness)
14 pts
partial points
Does not include all pertinent information of all 3: tobacco, alcohol, and drug use including pack/year, type, quantity, duration of use of tobacco, alcohol, drug Excludes pertinent content or includes non-pertinent content
10 pts
partial points
Includes only 1-2 components of tobacco, alcohol, drug use including pack/year, type, quantity, duration of use of tobacco, alcohol, drug Excludes pertinent content or includes non-pertinent content
15 pts
This criterion is linked to a Learning OutcomeHealth Promotion
10 pts
Full Marks
Includes all information and components that are pertinent to the CC/HPI. DO NOT include unless definitively leads to a diagnosis – points will be deducted for including all for no reason (see rubric) or not including a pertinent topic. This is the key to this assignment. Last Exams & dates – physical exam, eye exam, and dental exam Health screenings & dates: age appropriate, date of screening Immunizations: date & type
9 pts
partial points
Addresses 2 components Includes partial information. Does not include all pertinent information.
7 pts
partial points
Does not include full information, missing pertinent information. Includes only 1 component Excludes pertinent content or includes non-pertinent content
10 pts
This criterion is linked to a Learning OutcomeReview of System (ROS)
15 pts
Full Marks
ROS contains only subjective information. ROS includes information and components of history that are pertinent to the CC/HPI. Includes all key questions of the system that would lead to diagnosis. Correct terminology utilized. Contains pertinent positives listed first followed by negatives written in correct format. DO NOT include unless definitively leads to a diagnosis – points will be deducted for including all for no reason (see rubric) or not including a pertinent topic. This is the key to this assignment. General Skin HEENT Neck & Thyroid Lymphatic Respiratory Cardiovascular Peripheral Vascular Abdomen Musculoskeletal Neurological Hematological Endocrine Psychiatric
14 pts
partial points
ROS contains subjective information in a comprehensive format for most systems. ROS does not contain objective information. Incorrect terminology utilized. Does not contain pertinent positives and negatives and/or they are not written in correct format. Missing key questions necessary to lead to diagnosis.
10 pts
partial points
ROS contains objective information. Format inconsistent and not comprehensive for most systems. Incorrect terminology utilized. Does not contain pertinent positives and negatives and/or they are not written in correct format. Missing key questions necessary to lead to diagnosis. Excludes pertinent content or includes non-pertinent content
15 pts
This criterion is linked to a Learning OutcomePhysical Exam Findings
20 to >15.0 pts
Full Marks
Exam contains only objective findings pertinent to the CC/HPI. *Includes advanced health assessment exam techniques related to each system. Include exam results/findings, NOT description of exam Correct terminology utilized. Includes all exams necessary to lead to diagnosis. Contains pertinent positives listed first followed by negatives written in correct format. DO NOT include unless definitively leads to a diagnosis – points will be deducted for including all for no reason (see rubric) or not including a pertinent topic. This is the key to this assignment. Do not include any system that is not listed below (breast, prostate, or GU system). General Skin HEENT Neck & Thyroid Lymphatic Respiratory Cardiovascular Abdominal Peripheral Vascular
15 to >10.0 pts
partial points
Includes only objective information pertinent to CC/HPI. Missing pertinent advanced health assessment exam techniques. Missing pertinent results/findings Correct terminology utilized. Includes all exams necessary to lead to diagnosis. Contains the majority of pertinent positives listed first followed by negatives written in correct format. Missing key questions necessary to lead to diagnosis.
10 to >0 pts
partial points
Includes subjective information Includes description of health assessment techniques. Writes narrative with non-pertinent content first Missing key questions necessary to lead to diagnosis. Includes or excludes pertinent content Includes any system breast, prostate, or GU system
20 pts
This criterion is linked to a Learning OutcomeContent
2 pts
Full Marks
Organized is focused to appropriate section. Content structure within sentences should be well organized and focused to topic. All spelling is correct. APA format is not required.
1 pts
partial points
Organized is less than 100 % focused to appropriate section. Content structure within sentences is not organized or focus shifts among topics. Spelling is less than 100 % correct. APA format is not required.
0 pts
No Marks
Organized is focused to appropriate section. Content structure within sentences should be well organized and focused to topic. All spelling is correct. APA format is not required
2 pts
Total Points: 100
Unformatted Attachment Preview
NGR 6002C Advanced Health Assessment
Note: Focused Visit Worksheet
Patient Initials/DOB: __________________
Chief Concern/Complaint (CC):
History of Present Illness (HPI): Write in paragraph format. OK to use short, incomplete sentences. Include
all components necessary from the acronym OLDCART but DO NOT use the term OLDCART or write Onset
_____
Medications: Include name, dose, frequency, reason
Prescription (include medical cannabis and oral contraceptives)
Non-prescription drugs or medications
Vitamins, minerals, or herbal supplements/herbals
Allergies: Include reactions to medications, environment, food, latex
Personal & Social History: Only include information and components of social history that are pertinent
to the CC.
Always include:
Tobacco – type, quantity, duration (pack/year)
Alcohol – type, quantity, frequency
Drug use (illicit substance)
DO NOT include unless definitively leads to a diagnosis – points will be deducted for including all for
no reason (see rubric) or not including a pertinent one. This is the key to this assignment.
Exercise and Diet – type & frequency of exercise; usual daily foods, caffeinated products
Living & home situation – significant others, sources of stress, alterations in ADL’s
Safety – seat belts, helmets, sunblock, smoke detectors, medical alert devices, etc. Alterations in
sleep pattern
Religious or spiritual beliefs
Occupational — current job or retirement, possible exposures, deployment
Recent Travel (possible exposures, illness)
Health Promotion: Only include information and components pertinent to the CC.
DO NOT include unless definitively leads to a diagnosis – points will be deducted for including all for
no reason (see rubric) or not including a pertinent topic. This is the key to this assignment.
Last Exams & dates – physical exam, eye exam, and dental exam
Health screenings & dates: age appropriate, date of screening
Immunizations: date & type
Review of Systems (ROS): Only include information pertinent to the CC. Subjective information only.
Use correct terminology. Contains pertinent positives listed first followed by negatives written in correct
format. DO NOT include unless definitively leads to a diagnosis – points will be deducted for including
all for no reason (see rubric) or not including a pertinent topic. This is the key to this assignment.
General
Sin
HEENT: Head, Eyes, Ears, Nose and Sinuses, Throat (mouth & pharynx)
Neck & Thyroid
Lymphatic
Respiratory
NGR6002C Spring 2021 to Bates
NGR 6002C Advanced Health Assessment
Note: Focused Visit Worksheet
Cardiovascular
Gastrointestinal
Peripheral Vascular
Musculoskeletal
Neurological
Hematological
Endocrine
Psychiatric
Exam Findings: Only include information pertinent to the CC. Exam contains only objective information. Include
exam techniques as included in OSCE rubric. Correct terminology utilized. Contains pertinent positives listed first
followed by negatives written in correct format. DO NOT include unless definitively leads to a diagnosis –
points will be deducted for including all for no reason (see rubric) or not including a pertinent topic. This is the
key to this assignment. Do not include any system that is not listed below (breast, prostate, or GU system).
General
Sin
HEENT: Head, Eyes, Ears, Nose and Sinuses, Throat
Neck & Thyroid
Lymphatic
Respiratory
Cardiovascular
Gastrointestinal
Peripheral Vascular
Abdominal
NGR6002C Spring 2021 to Bates
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