Main or Primary diagnosis Discussion
Faculty Comments: Faculty Comments: Points Description
Subjective
5 Chief complaint stated in patient’s own words.
10 HPI, PMH, PSH, Family History, Social Habits,
10 Contains all systems relevant information to make assessment
with normal and abnormal findings.
20 Objective present and contains all pertinent objective
information available (drug allergies, physical findings, drug list,
etc)
20 Assessment presents justification for Main or Primary diagnosis
15 Assessment rules out other potential disorders
5 Plan contains discussion of therapy options with pros and cons
of each. Also
10 Plan stated as directives (start, stop, non-pharmacologic and
pharmacologic treatment etc)
5 Plan include monitoring and follow up
Comments: please explain the 3 differential dignosis in further
notes