UST FACULTY OF MEDICINE & SURGERY

Department of Medicine
Medicine 2
The Patient Write-Up Grading Rubric
(Clinical History, Case Discussion and Master Problem List; Version Aug. 2017)

Initials of Student: Subsection Date: August 29, 2018

Facilitator:

☑ Original manuscript 1ST Revision 2nd Revision

A. HISTORY TAKING
1. General Data/Patient Information: (Should contain ALL information listed below) (3)
Name (initials only): Age: Gender:
Birthday/Birthplace: Nationality/Citizenship: Religion:
Educational attainment: NONE Civil Status: Single
Occupation: None
Home Address:
Provincial address:
Contact number:
Informant/s (Reliability – good, fair, poor): Niece
Date admitted in USTH: Date of Interview: August 20, 2018

2. Chief Complaint/s: (State patient’s main complaint or concern in his/her own words eg. Pilipino; Enclose in parenthesis the correct and appropriate English
translation.) (2)

3. History of Present Illness (HPI): (Make a thorough and organized HPI. Write in chronological order; Describe symptoms according to onset, location, duration,
character, aggravating or associated factors, relieving factors, temporal factors and severity (e.g. ALL PAIN SYMPTOMS); Note the pertinent negatives and positives.)(8)

4. Past (Medical) History: (Make a thorough and organized past medical history using a “bullet-format” Record previous childhood and adult medical and surgical
illnesses and hospitalizations; injuries/ accidents; obstetric/ gynecologic history ie. family planning method used if relevant to the diagnosis; Immunizations; allergies --if
none, write “No known drug allergies”; List medications -include generic names; herbal/supplements & adverse drug reactions; Include current health status/risk factors
ie. nutrition, sleep, exercise, smoking, alcohol, illicit drug use); Use only standard and commonly accepted abbreviations.) (5)

5. Family History: (List the common genetic disorders and major health conditions in the patient’s family - identify specific family members; include Medical
Genogram or Family Diagram ie. 3 - 4 generations) (2)

6. Personal/Social History: (Briefly describe the cultural background, family structure & relationships, marital status, stress factors, educational data, economic
status; environmental data; occupational/ employment history; sexual history); Elaborate on the social history (*see NEJM Oct 2, 2014 issue for reference) (2)

7. Review of Systems: (Review and list ALL symptoms pertinent to the working diagnosis but were not accounted for in the HPI. Do not repeat any data already
mentioned in the HPI); Do not include PE findings or diagnosis in the ROS.) (3)
25 –---------------------- 20 19 -----------------------– 15 14 –-----10--------5-------0
Rubrics for grading Able to identify and Described important Incomplete history; __ No need to
of HISTORY discriminate important clinical data pertaining to Recorded history but Rewrite history
historical information. chief complaint although unable to obtain important
(Max. 25 points)
Made an organized, incomplete. Noted some clinical data relating to __ Rewrite & take note of
______________ thorough, and complete discordant clinical chief complaint/Organ- corrections
history. information. system

B. PHYSICAL EXAMINATION
__________ Date of Admission (Current hospital confinement at USTH-CD)
__________ Date (*current) this physical exam was performed by the medical student

NOTE: Ideally, the PE findings to be recorded here should include both data on ADMISSION date and the *current date for purposes of writing a good case
discussion by the student
1. General Survey: (Make a complete and accurate general survey; Describe the appropriate and relevant findings.) (1-2)

2. Vital Signs: (Record the current vital signs including anthropometric data eg. BMI) (1-2)
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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine 2
The Patient Write-Up Grading Rubric
(Clinical History, Case Discussion and Master Problem List; Version Aug. 2017)

3. Skin: (Describe the relevant findings adequately and include images of lesions - obtain patient’s consent; State pertinent negatives) (1-2)

4. HEENT/Neck: (Describe and illustrate the appropriate findings adequately; include thyroid and fundoscopic findings if relevant and contributory) (1-2)

5. Thorax/Breast/Lungs: (Describe and illustrate the appropriate findings adequately. Report pertinent negatives). (1-3)

*Lung Auscultogram: (Illustrate the pertinent “I – P – P – A” lung findings using the UST-CRM auscultogram); should be handwritten, NOT Copy-Paste” (1-2)

6. Cardiovascular: (Describe the appropriate findings adequately. Observe the correct sequence i.e. “I - P - A”. State pertinent negatives). (1-2)

*Heart Auscultogram: (Draw the pertinent cardiovascular findings i.e. heart sounds, murmur - including the JVP, CAP and peripheral pulses) Handwritten NOT
“Copy-Paste”(1-2)

7. Gastrointestinal: (Describe the relevant findings adequately; Note the correct sequence of abdominal exam ie. I-A-P-P; Include rectal if necessary; State
pertinent negatives) (1-3)

8. Musculoskeletal: (Describe the relevant findings adequately; Include MMT if necessary; State pertinent negatives) (1-2)

9. Extremities: (Describe the relevant findings adequately; State pertinent negatives) (1)

10. Neurological: (Describe the appropriate findings adequately; Note correct sequence of examination. State pertinent negatives) (1-2)

Rubric for grading 25 –------------------------- 20 19 ---------------------– 15 14 –---------- 10 ----------- 0

of Physical Exam. Performed a complete Lacks some Performed an incomplete __ No need to Rewrite PE
and focused PE. important/relevant PE & focused PE. Did not

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine 2
The Patient Write-Up Grading Rubric
(Clinical History, Case Discussion and Master Problem List; Version Aug. 2017)

findings. perform some important / __ Rewrite & take note of

(Max. 25 points) relevant PE exam on the corrections
______________ organ-system involved.

C. CASE DISCUSSION (Problem-Based)

1. PROBLEM LIST
Note: Please use the Master Problem List (MPL) sheet. Read carefully the “DEFINITION OF A PROBLEM” at the bottom of the MPL table.
Note: The chief complaint may be highlighted as a distinct problem statement in the MPL to emphasize USTH patient-focused care.
Problem #1

Problem#2

Problem#3

Rubric for grading 5-------------------------------------4 3-----------------------------2 1---------------------------0

of Problem List Organized, thorough, and Incomplete, MPL is grossly lacking; __ No need to rewrite
complete MPL. Understood and disorganized and too Critical thinking/ clinical
(Max. 5 points) applied correctly the concepts compartmentalized. reasoning was lacking. __ Rewrite & take note of
used when stating a “PROBLEM” Problems included were corrections
______________ as defined here. Higher order based only on hearsay.
thinking skills were evident Applied lower order
(Bloom’s) thinking skills
2. DISCUSSION
General Instruction: Discuss each problem in the MPL using the S-O-A-P format, where:

S = Subjective findings/ Symptomatology i.e. a BRIEF historical narrative pertinent to the problem statement (Patient
perspective)
O = Objective or physical examination findings (Doctor perspective)
A = Assessment or analysis of the S & O data; TO ENUMERATE at least 3 differentials and BRIEFLY explain your basis; to discuss
its relationship (i.e. association or correlation) with other problems in the MPL; to state the disease prognosis using the
most current literature
P = Plan of action for each problem in the MPL which includes: a) Diagnostic b) Therapeutic c) Education/ Prevention

(Note: Signs & symptoms may be repeated or rewritten in all enumerated problems only if deemed relevant and contributory
to the diagnosis and the differential diagnoses)

Problem #1: Maximum 15 pts._____________

S-

O-

A-

P- (D/T/E)

Problem #2: Maximum 15 pts._____________

S-

O-

A-

P- (D/T/E)

Problem #3: Maximum 15 pts._____________

S-

O-

A-

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine 2
The Patient Write-Up Grading Rubric
(Clinical History, Case Discussion and Master Problem List; Version Aug. 2017)

P- (D/T/E)

(Note: If more than 3 problems are being considered, PRIORITIZE your list (MPL) according to the order of importance, severity and/or
chronology of the problems identified. ALWAYS BE CONSISTENT (i.e. original word/phrase and numbering) WHEN WRITING YOUR PROBLEM
STATEMENTS IN YOUR MPL & DISCUSSION
Rubrics for Diagnostics 8 -------------7------------6 5 ------------4-------------3 2 -----------1-----------0
Complete, organized, brief, and Lacking or included Majority of the S & O __ No need to rewrite
(S- O- A-) included only the relevant subjective and/or objective data included are
SUBJECTIVE & OBJECTIVE data that are irrelevant or irrelevant to the __ Rewrite & take note of
(Max. 8 points)
data that are deemed noncontributory to the problem. Unable to corrections
______________ contributory to EACH problem problem. Explanation of S make a logical
and subsequently able to make a & O data lack basis or assessment/diagnosis
correct, logical and complete logic; Incomplete list of based on the S & O.
assessment including the differentials; Included Minimal explanation
prognosis. Able to enumerate the diseases that logically done; Lacking
differential diagnosis (from the should not be considered; differentials
MOST to the LEAST LIKELY)
with brief discussion.
Rubrics for Management 7 -------------6-------------5 4----------------------------3 2------------1----------0
Plans (P-) Able to formulate an appropriate Able to formulate a Diagnostic and
and rational diagnostic & satisfactory diagnostic & treatment strategies __ No need to rewrite
(Max. 7 points) treatment strategies focusing on treatment strategy but is are incomplete and
plans that will: a). Need utmost incomplete. Enumerated minimal. Enumerated __ Rewrite & take note of
______________ priority and should be plans included a) those plans included a) non- corrections
immediately done b). Confirm that may be delayed b) priority or just
and support the problem or were requested only for alternatives to support
address life-threatening baseline purposes c) may the problem b) offer
situations c). Provide the add financial burden to the little benefit to the
evidence to rule out differentials patient. patient, or c) costly
mentioned d). Address cost- procedures that will
containment schemes bearing in cause unnecessary
mind financial resources of the harm. No guidelines
patient. Incorporated recent or or journals cited.
up-to-date guidelines and briefly
cited relevant journals in the
discussion.

SCORE:
A. History (25) : _________
3. Final Disposition Very good / Satisfactory clinical Rewrite only that part of the Rewrite the entire History &
B. PE (25): _________
history and case discussion. No clinical history or Case PE; and re-submit on (Date)
*This portion to be filled need to rewrite. Discussion with corrections ____________ together with III. Case
up by your facilitator and re-submit on (Date) the initial manuscript. Discussion (50): _________
________ together with the
initial manuscript. Total: ________

Submitted by / Signature over printed name / Date:

_____________________________________________________________ _____________
Students name: (Last) (First) (Middle) Date

Facilitator: ______________________________________ Date Received/Checked: _____________

Signature over Printed Name

*NOTE: This form is for practice use only by medical students and is NOT an official hospital document

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine 2
The Patient Write-Up Grading Rubric
(Clinical History, Case Discussion and Master Problem List; Version Aug. 2017)

Last Name: Age: Gender:

Patient
First Name: Male Female
Name
Middle Name:
Date of Admission: Ward: Room/Bed No. Hospital No.

Out Patient Department (OPD) - USTH Emergency Room

Date of 1st consultation at OPD ______________________ Private Division Clinical Division
Chief Complaint/s or Chief Concern (Tagalog word or phrase/ English translation):

Date of MPL: MPL Revision No. (Please tick): 0 - 1- 2-

Problem PROBLEM LIST Date problem was Resolved to… Date

Number (List your Problem Statements according to the noted/recognized Upgrade your initial or original problem was
a permanently order of importance, severity and/or chronology; (Date of appearance problem statement (in Column 2) resolved
assigned Small alphabets may be used to designate or diagnosis of to a higher level of understanding a.to a higher
number; When problem; or evaluation (Final diagnosis)
attributes of a confirmed disease/disorder) eg. #1- level OR
revising the MPL, DM a.) nephropathy Date of intervention; Example: “see problem #”
b.Date
the original May use confinement 1- Cough & Dyspnea – see #4
disease
assigned no. is Note: The chief complaint or presenting problem is date if unknown or 2-Fever – see #4
cured
either retained or usually assigned to Problem #1 - to emphasize unsure ) 3-lobar infiltrates (cxr) – see #4
retired (i.e. not to and highlight our patient-focussed care approach. 4-PNEUMONIA
be re-used for
new problems

NOTE: Please read this definition-guideline carefully before constructing your MPL.
WHAT IS A PROBLEM?
a. It may be a symptom; a group of symptoms; an abnormal PE finding; laboratory or imaging results; a previously
confirmed diagnosis; a pathology report; a treatment intervention or surgical procedure
b. Any condition needing further diagnostic and/or treatment intervention and follow-up medical or surgical care.
c. ALL problem statements must be supported by hard data.
d. No hearsay evidence is allowed.
e. AVOID writing in the “Problem List” column the following words/phrases: “Possible or probably due to; to consider
(T/c); rule in (R/i); rule out (R/o); Secondary to; versus (vs) and question mark (?)
f. Your differential diagnoses should be written in the assessment portion of the progress notes -- NOT in the MPL form.

Prepared by:

3rd Year Medical Student ______________________________________ Date:

Signature over Printed Name
Junior Intern/ PGI/
______________________________________ Date:
Resident
Signature over Printed Name
Validated by:
Attending Physician/
Consultant/ Medicine II ______________________________________ Date:
Facilitator Signature over Printed Name
Disposition: Revise this MPL No need to revise

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 UST FACULTY OF MEDICINE & SURGERY
Department of Medicine
Medicine 2
The Patient Write-Up Grading Rubric
(Clinical History, Case Discussion and Master Problem List; Version Aug. 2017)

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