Final Written H&P Head-to-Toe
Final Written H&P Head-to-Toe
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Provider’s name
1 pts
Full Marks
0 pts
No Marks
1 pts
This criterion is linked to a Learning Outcome Patient’s initials
1 pts
Full Marks
0 pts
No Marks
1 pts
This criterion is linked to a Learning Outcome Date of exam
1 pts
Full Marks
0 pts
No Marks
1 pts
This criterion is linked to a Learning Outcome Patient’s DOB/Age
2 to >0.0 pts
Full Marks
0 pts
No Marks
2 pts
This criterion is linked to a Learning Outcome Chief Complaint
1 pts
Full Marks
0 pts
No Marks
1 pts
This criterion is linked to a Learning Outcome Patient’s Gender/Sexual orientation
2 to >0.0 pts
Full Marks
0 pts
No Marks
2 pts
This criterion is linked to a Learning Outcome HPI (onset, symptoms—location/quality/quantity/timing Setting/aggravating or relieving factors/associated problems)
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome PMH: a. Childhood diseases b. Adult diseases c. Accidents/injuries d. Immunizations
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Allergies (drugs/contrast, bandages, pollen, plants, food, animal, occupational)
3 to >0.0 pts
Full Marks
0 pts
No Marks
3 pts
This criterion is linked to a Learning Outcome Current Medications:
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Social Hx: a. Smoking b. ETOH c. Caffeine d. Substance abuse e. Education attained f. Occupation g. Marital status h. Children? i. Lifestyle j. Diet k. Sports/activities/hobbies
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome Family Hx: a. Parents b. Siblings c. Children Include ages, chronic medical conditions, malignancies, hereditary diseases, causes of death and age at death, suicide?
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Reproductive/Sexual Hx: a. LNMP b. Date of first menarche c. Gravida/Para (TPAL) d. Libido e. STD hx f. contraception
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome ROS: General Weight gain/loss, appetite, sleeping habits, fever, fatigue, weakness, general health
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome ROS: Skin Color changes, rashes, sores, pain, pruritis, hemorrhages, hair loss, changes in nails
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome ROS: HEENT Headache, migraine, vision changes, cataracts, diplopia, otalgia, otorrhea, hearing changes, rhinorrhea, epistaxis, sinus drainage/pain, sore throat, hoarseness, dental pain/missing teeth, jaw pain or clicking
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome ROS: Breasts Discharge, pain, enlargement, lesions, galactorrhea
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome ROS: Respiratory Pleuritic pain, tachypnea, asthma, bronchitis, COPD, TB, orthopnea, DOE, sputum production, hemoptysis
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome ROS: CV Chest pain, palpitations, pedal edema, cyanosis, claudication, phlebitis, hypertension, orthostatic hypotension, dizziness
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome ROS: GI Nausea, vomiting, diarrhea, anorexia, dysphagia, hematemesis, bloating, flatulence, abdominal pain, constipation, clay-colored stools, hemorrhoids, hematochezia, melena, jaundice, GERD/heartburn
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome ROS: GU Urinary frequency, dysuria, nocturia, flank pain, hematuria, penile discharge/vaginal discharge, incontinence (and details of same if positive), urinary retention, UTI hx, STD hx, fertility/contraception/orgasms
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome21. ROS: Musculoskeletal Muscle pain, joint pain, loss of function, decreased ROM, loss of strength, joint swelling, hx of fractures/dislocations, hx of trauma/surgeries, back pain
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome ROS: Neuro Dizziness, headache, sleep changes, syncope/near-syncope, paralysis, paresthesia, hx of LOC, hx of seizures, hx of loss of bowel/bladder control, loss of memory
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome ROS: Endocrine Polyphagia/uria, goiter, lethargy, hot/cold intolerance, nervousness, obesity, change in sex characteristics, amenorrhea, gynecomastia, flushing
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome ROS: Psychiatric Anxiety, depression, hallucinations (auditory/visual, tactile, gustatory, olfactory), suicidal ideation, hx of suicide attempt, hx of IVC, homicidal ideation, delusions
10 to >0.0 pts
Full Marks
0 pts
No Marks
10 pts
This criterion is linked to a Learning Outcome VS (temp, HR, BP, RR, O2)
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome General: must be at least 3 items from p71
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Head: Skull, scalp, face – shape, size, profile, symmetry, pain, meningeal signs?
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Ears: shape/symmetry of auricles, canals, drums, auditory testing (Weber, Rinne, whisper)
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Eyes: visual acuity, visual fields, symmetry, drainage, eye position, PERRLA, EOMI?, ophthalmoscopy (red reflex, optic disc, vessels, papilledema, hemorrhages, retinopathy?)
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Nose: external and internal, patent nares? Drainage? Sinus pain? Turbinates? Bleeding? Olfacation?
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Throat/Mouth: jaw motion, lips, salivary glands, cheeks, tongue, teeth, gums, oral mucosa, pharynx, tonsils, uvula, soft/hard palate
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Neck: flexibility, shape, symmetry, goiter/thyroid, lymph nodes (and name), trachea, auscultate carotids, JVD?
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Heart: palpate PMI, apical impulse, radial pulse, heart sounds and extra sounds (MRG and describe)
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Lungs: shape/size/symmetry, respiratory movements, accessory muscles, compression pain, breath sounds? Decreased? Adventitious? describe
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Abdomen: skin, umbilicus, shape, volume, symmetry, distension, hernias, scars, bowel sounds x 4 quads and describe, guarding? Tenderness? Rebound pain? Masses? Liver measurement, gallbladder? Kidneys/CVA tenderness?
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning Outcome Musculoskeletal: Muscle strength (5/5, etc); joint ROM and document, peripheral pulses and document (at least 1 UE and 2 LE), DTR, back movement/limitation? Alignment?
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
This criterion is linked to a Learning OutcomeNeuro: Cranial Nerves CN 1-12
12 to >0.0 pts
Full Marks
0 pts
No Marks
12 pts
This criterion is linked to a Learning Outcome DTR (at least 2 UE bilateral and 2 LE bilateral and document appropriately)
8 to >0.0 pts
Full Marks
0 pts
No Marks
8 pts
This criterion is linked to a Learning Outcome Mini Cog Exam: document as in rubric for examination
7 to >0.0 pts
Full Marks
0 pts
No Marks
7 pts
This criterion is linked to a Learning Outcome ASSESSMENT STATEMENT including 3 problems or education deficits including ICD 10 codes
15 to >0.0 pts
Full Marks
0 pts
No Marks
15 pts
This criterion is linked to a Learning Outcome PLAN: at least 3 steps to address the problem list
15 to >0.0 pts
Full Marks
0 pts
No Marks
15 pts
This criterion is linked to a Learning OutcomeSignature and Date
5 to >0.0 pts
Full Marks
0 pts
No Marks
5 pts
Total Points: 273
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