Current Regis Time
| Criteria | Exemplary Exceeds Expectations |
Advanced Meets Expectations |
Intermediate Needs Improvement |
Novice Inadequate |
Total Points |
|---|---|---|---|---|---|
| Chief Complaint and History of Presenting Illness (HPI) Chief Complaint/CC or reason for the visit (2 points) History of Presenting Illness (HPI) –location, quality, quantity or severity, timing (onset, duration, frequency), setting in which it occurs, factors that aggravate or relieve the symptoms, and associated manifestations (16 points) Patient’s response to his or her symptoms and what effect the illness had had on the patient’s life (2 points) |
Concise and clear CC as described by patient HPI includes a minimum of seven attributes of the presenting symptom with appropriate detail 20 points |
Clear CC as described by patient HPI missing 1 attribute of presenting symptom 17 points |
CC as described by patient, may not be concise or clear HPI missing 2 attributes of presenting symptom 15 points |
CC not identified, concise, or clear HPI missing >3 attributes of presenting symptom 13 points |
20 |
|
General Information about the patient: – 3 points Name (first initial only); age, and gender (1 point) Source of information; note relationship to patient, if relevant (1 point) Reliability of information (1 point) Past Medical History (PMH) – 7 points Childhood illnesses (1 point) Adult illnesses with dates of diagnosis (medical, psychiatric, and obstetric/gynecologic) (4 points) Hospitalizations/ER visits (2 points) Past Surgical History (PSH) – 2 points Procedures and dates Health Maintenance Practices – 6 points Screening as age, gender, and risk appropriate (include dates) (3 points) Immunizations (2 points) Home safety concerns (1 point) Family History (FH) – 2 points Genogram or description of age and health, or age and cause of death of siblings, parents, and grandparents; Personal or Social History (SH) – 10 points Educational level, past/current occupation (2 points) Family of origin and current household (2 points) Lifestyle including physical activity (1 point) Tobacco use in pack years, desire to quit (2 points) Alcohol use and CAGE screening (2 points) Other drug use, past treatment, current status (1 point) Medications – 5 points Name, dose, route, and frequency of prescription and over–the–counter medications; including compliance (3 points) Allergies to medications and reaction (2 points) |
Subjective history is descriptive and complete and includes information related to the chief complaint, including pertinent negatives 35 points |
Subjective history is descriptive and complete and includes pertinent information related to the chief complaint; may miss one component 28 points |
Subjective history is descriptive and includes pertinent information related to the chief complaint but misses 2–3 components 24 points |
Subjective history may or may not be descriptive and misses >4 components or information pertinent to the chief complaint 20 points |
35 |
| Review of Systems (ROS) General (weight, weakness, fatigue, fever) (3 points) Skin (2 points) HEENT (5 points) Neck (2 points) Breasts (1 point) Respiratory (2 points) Cardiovascular (2 points) Gastrointestinal (2 points) Peripheral Vascular (2 points) Urinary (1 poin) Genital (2 points) Musculoskeletal (2 points) Psychiatric/depression screen (5 points) Neurologic (2 points) Hematologic (1 point) Endocrine (1 point) |
Review of Systems is descriptive and complete and includes pertinent positive and negative symptoms related to the chief complaint 35 points |
Review of Systems is descriptive and complete and includes pertinent positive symptoms related to the chief complaint 28 points |
Review of Systems is descriptive but misses 1–2 components 24 points |
Review of Systems may or may not be descriptive and misses >3 components 20 points |
35 |
| Documentation (10 points) Documentation of subjective findings |
All data included with appropriate detail Organized Correct terminology, spelling, and grammar 10 points |
Missing 1–2 components or minor detail Organized Terminology, spelling, or grammar errors (1–3) 8 points |
Missing 3–4 components or significant detail Minor errors in organization Terminology, spelling, or grammar errors (4–5) 7 points |
Missing >5 components or significant detail Disorganized flow of data Terminology, spelling, or grammar errors (>5) 6 points |
10 |
| Total Points | 100 | ||||