Dress Code in Clinical Environments

Please see the College of Medicine dress code. For all real or simulated clinical learning activities (e.g., those that involve patients or standardized patients), all students must maintain an appearance that demonstrates respect and meets professional standards.  You will receive feedback about the professional appropriateness of your grooming and attire from standardized patients, faculty, portfolio […]

Clinical Skills History and Physical Examination Documentation Example

Date/Time of Encounter:  Source/Reliability:  Patient Identification:   History Chief Complaint [in patient’s own words, if possible] History of Present Illness  [Patient’s history of current illness] [Pertinent positives and negatives]  Use CLOSER for symptom description. Use OPQRST.AAA to elicit details of pain. Medications [current medications, dosages, route of administration; generic names only]  Allergies [allergies to medications and if […]

Guide to the Medical History

Protect Patient Confidentiality: DO NOT include any Protected Health Information (PHI) in your real patient write-ups. You may report their age but not date of birth, and do not include their first or last name.   It may be easiest to make up a fictitious name and include it in quotes in the Pt ID section at the very beginning of the write-up. […]