Essentials for Students- Visit Notes
Each week, starting with the first week of the clerkship, you must give to your site coordinator or principal preceptor the visit note for a patient you treated as a major provider. These notes should be in the format specified in the prospectus [see section entitled "visit notes"]. Be sure to also give this preceptor the visit note evaluation form. You may expect to receive your annotated note and the completed evaluation form within 48 hours. Your note should be appropriately short (rarely more than two handwritten pages) but complete for the problems identified during the visit. Be sure the review of systems is complete for all problems and that you discuss a differential diagnosis. Justify your diagnosis and plans.
If the notes you write as part of routine care are complete and suitably structured, a copy will suffice for this exercise. Otherwise re-do your official note. If you choose to submit a note on a new patient (complete H&P), it should be as long and detailed as an in-patient admission note.
You will be graded for each note on a scale of outstanding, excellent, very good, satisfactory, and poor. In your final evaluation for the clerkship, we will indicate your average grade, with missing notes graded as “poor”. To receive an "outstanding" grade on any note, you must 1) date the note, 2) follow a SOAP format, 3) clearly indicate a chief complaint, 4) include a complete history for the CC, 5) indicate medications with dosages (unless unavailable), 6) indicate a full pertinent physical examination for the CC, 7) write in succinct, clear prose and avoid obscure abbreviations and symbols, 8) write an assessment that appropriately evaluates clinical evidence to create a sensible differential diagnosis, 9) indicate a plan that is appropriately complete and does not include grossly inappropriate testing or therapy, 10) follow guidelines in prospectus and 11) sign your name clearly or print it. In general, very simple problems (e.g.: routine F/U hypertension) will not warrant an "outstanding" grade unless the clinical evaluation and assessment is extraordinary (and beyond what might be expected for a routine evaluation of the problem).