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Clinical Case Write-Up Rating Form v3

This document contains a clinical case write-up rating form used to evaluate medical students at Universiti Sains Malaysia School of Medical Sciences. The form includes ratings in 10 areas of a case write-up from chief complaint to references on a scale of 1 to 10. Areas assessed include history of present illness, physical exam, differential diagnosis, management plan, and discussion. Students are also given an overall global rating and feedback on their strengths and areas for improvement. The assessor completes the form to evaluate the student's case write-up against the expected performance level.

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Alexandra Duke
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102 views2 pages

Clinical Case Write-Up Rating Form v3

This document contains a clinical case write-up rating form used to evaluate medical students at Universiti Sains Malaysia School of Medical Sciences. The form includes ratings in 10 areas of a case write-up from chief complaint to references on a scale of 1 to 10. Areas assessed include history of present illness, physical exam, differential diagnosis, management plan, and discussion. Students are also given an overall global rating and feedback on their strengths and areas for improvement. The assessor completes the form to evaluate the student's case write-up against the expected performance level.

Uploaded by

Alexandra Duke
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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UNIVERSITI SAINS MALAYSIA SCHOOL OF MEDICAL SCIENCES

CLINICAL CASE WRITE-UP RATING FORM*


Student’s Name
Phase II Year 3 4 5 Matric Number

Assessor’s Name
Department

Patient’s R/N
Age Sex  Male  Female

Assessor Rating
10 9 8 7 6 5 4 3 2 1 N/A
Chief Complaint
Clearly and concisely stated
          
HOPI
Well-organized, critical information
and pertinent related information
included; there is evidence that the
          
student has a rudimentary differential
in mind.
Other History – PMH, Meds,
All, FHx, SHx, PaedHx, O&GHx,
ROS           
Complete with appropriate details;
understands relevance to the case.
Physical Examination
Complete examination, clearly
described with appropriate emphasis           
on aspects relevant to the Chief
Complaint
Data Collection -labs, x-rays,
ECGs, etc.
Key information present and clearly
documented; rationale for data
          
provided, results interpreted and
applied to patient care.
Differential Diagnosis
Reasonable possibilities are
addressed; student clearly did
          
additional reading.
Management Plan
Work-up / management plan
addresses all active problems and
shows evidence of outside reading and
understanding of pathophysiology (a
thoughtful plan rather than a
          
“shotgun” approach – both of which
can be technically complete). EBM,
bioethical and psychosocial issues
considered.
Discussion
Shows good understanding of the case
          
and application of EBM and relevant
basic science knowledge.
References
References properly cited and           
appropriate for the level of study
Please give an overall rating of the student against the performance expected at their level of study
GLOBAL RATING
          

Assessor Feedback
Student Strengths Areas for Improvement

Assessor Signature

Date
* Modified from http://clerkship.medicine.ufl.edu/portfolio/patient-care/write-ups/criteria-for-grading-write-ups/ accessed 15/11/2016

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