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Old 08-17-2013
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Thumbs Up Grading of patient note.

I took this from another forum. Might be helpful.

This is how most of the american medical schools evaluate their students patient note. This gives an idea how patient note may be evaluated in USMLE CS. As USMLE mentions on its website in January that every part of the patient note is important and carries weightages in scoring, the below mentioned scoring evaluation gives some insight into how patient note will be scored in CS.

1. Documentation of History and PE 30 points

Key Hx and PE findings are missing or incorrect

Most key positive findings present but poorly documented or disorganized or missing pertinent negatives

Most key positive findings well documented and organized, may miss a few pertinent negatives

All key information present, concise and well organized with little irrelevant info

2. DDX 30 points

0-1 of the correct diagnoses listed

Two of the three diagnoses listed, in any order

All three diagnoses listed, incorrect rank order

All three diagnoses listed and correctly rank ordered

3. Justification of Diagnosis 30 points

No justification provided

Several incorrect links between findings and Dx

Only a few missing or incorrect attributions, which would not impact Dx

Links to diagnoses are correct and complete

3. Plan for Immediate Diagnostic Workup 10 points

Diagnostic workup places patient in unnecessary risk or danger

Ineffective plan for diagnostic workup essential tests missed, irrelevant tests included

Reasonable plan for diagnostic workup, may have some unnecessary tests

Plan for diagnostic workup is effective and efficient, includes all essential tests, and few or no unnecessary tests.
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