Reason for Admit for Inpatient

Levels of Achievement
Criteria Below Expectations Minimal Expectations Expectation
Identifying Data; Chief Complaint


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(-10 points)
Fails to provide information. For this section, -10 if any of the two sections are incomplete. (0 points)


(0 points)
Provide brief demographics, reason for visit or who referred, provide working diagnosis(es).


History of Present Illness (Includes ED [etc.] reason for admit for Inpatient Note)










(0 points)
Fails to provide information.










(1 to 16 points)
Limited data, omits required data, does not address interval history, such as course of previously identified symptoms, effectiveness of current treatment regimen or interventions; does not address onset of new symptoms, adherence to treatment plan, etc.; Fails to compare improvement or worsening of specific symptoms quantified in previous note (e.g., “sleeping 6 hours/ night versus 4 hours previously) when applicable; data insufficient to justify current working diagnosis, plan, etc.

(17 to 20 points)
Focused interval history, including (but not limited to) new onset, change in symptom frequency, duration, mitigating factors, etc.; Effectiveness of interventions from previous encounter(s) (e.g., medications, therapy, etc.). What has gotten better, worse, or stayed the same; attempts or strategies to self-manage symptoms; change in stress, sleep, changes in appetite, mood, and behavior; changes in functional impairment; obtain data sufficient to justify current working diagnosis; etc. (see Carlot)




Past and Family Psychiatric History; Social and Substance History






(0 points)
Fails to provide information. No points will be given if any of these 4 sections are incomplete. If unable to obtain, must provide a reason.






(1 to 5 points)
Lacks adequate detail relevant to new onsets/or interval changes to information obtained in previous assessment (or last visit) not limited to: diagnostic date, diagnosis, treatment and response, medications, types of substances, amount, frequency, how they use, last use, and most ever used; education, employment, etc.



(6 to 7 points)
Updated from previous encounter noting things that could have potentially changed since last visit (e.g., financial status, support persons, occupation, etc.); completion of each section, providing details relevant to information obtained. (See Carlot)







Treatment of Pertinent Comorbidities; Allergies; Medical History; Medical Review of Systems; Family Medical History









(0 points)
Fails to provide information. No points will be given if any of these 5 sections are incomplete. If unable to obtain, must provide a reason.






(1 to 2 points)
Interval medications listed by name only without dosage, schedule, form. Interval detail is not provided since previous assessment (or last visit) not limited to: comorbidities (e.g., changes in use of CPAP, amount of O2 being used, etc.) Medical review of systems should always be conducted on each assessment. MROS does not align with information provided elsewhere in the document.

(3 points)
Interval and detailed completion of each section based on changes from previous encounters, etc.








Use of assessment tools; Mental Status Exam; Pertinent Labs/Vitals







(0 points)
Fails to provide information. No points will be given if any of these 3 sections are incomplete.





(1 to 3 points)
Improper assessment tool chosen. Lacks adequate utilization, scoring, interpretation of assessment tools. MSE does not reflect individual patient data. Does not align with presentation provided in HPI. Pertinent labs are not reflective of individual patient’s needs or relevant history.


(4 to 5 points)
Relevant assessment tool used. Pertinent labs identified based on medications being used or prescribed. Pertinent labs used as a medical rule out. MSE completed.














(0 points)
Fails to provide information in either section.
Non- DSM 5 diagnostic labels




(1 to 16 points)
Lacks adequate justification for diagnosis based on assessment data provided in HPI. Fails to assess for or attend to diagnostically relevant data. Fails to address relevant symptoms; does not provide rationales; Provides incorrect diagnostic label or coding.

(17 to 20 points)
Focused assessment, including (but not limited to): Utilization of proper assessment techniques with focus on relevant symptoms; synthesis of HPI data highlighting pertinent information that justifies diagnosis and treatment plan; arrives at appropriate diagnosis and differentials; lists accurate diagnostic labels and codes.

Treatment Plan/ Education


(0 points)
Fails to provide plan or patient education.
No points will be given if either
of these sections
are incomplete.

(1 to 16 points)
Plan limited, does not address additional patient needs, medications, follow-up health promotion issues or need for referral. Safety. Lacks one or more components listed under expected components.

(17 to 20 points)
Comprehensive plan, including but not limited to: medications (with start dose, titration, etc.), behavioral recommendations, labs, referrals, safety plan, and recommended follow-up, specific and relevant patient education.


What I Learned/What I would do differently/ sections (These two sections should be APA)









(0 points)
No comments included or less than 1 page in length. No points will be given if any of these three sections are incomplete







(1 to 21 points)
Minimal comments provided. Comments lack adequate self-awareness regarding learning opportunities. Lacks sound reasoning for his/her decision making. Uses quotations from the citing article instead of own words. Lacks understanding or rationale for preceptor’s decision making. Does not reflect pertinent or relevant data or information from clinical note (generic information). Reference included, but either not relevant in its support of statement or not “best practice or evidenced-based.”

(22 to 25 points)
Comments address new information learned or discovered. Focuses on pertinent data from the clinical note and provides complex reasoning skills. Writing reflects introspection on interaction. Provides sound reasoning for decision making. Provides two evidenced based articles (published within the next 5 years) to clinical decision making.





Total: 100 points.

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