Student / Patient “Clinical Worksheet”
OBJECTIVE: Support clinical supervisors in the utilization of a Clinical Worksheet to expedite the development of core
competencies in medical students and residents during clinical training.
BACKGROUND: In the clinical training environment, students and residents utilize patient care documents (H&P forms,
SOAP notes, Progress notes, etc) to express their clinical thoughts, impressions, treatments, management plans, etc
regarding patients with whom they interact. Unfortunately, patient care documents have evolved to primarily serve
medical, reimbursement and legal roles. Such documents do not provide learners an optimal means of communicating
how they are utilizing their own medical knowledge and patient-derived findings to draw the conclusions needed to
competently perform core clinical tasks such as diagnosing, treating and managing their patient’s problem(s). As a result,
learners often do not receive the feedback and guidance they need from seasoned clinical supervisors to expedite their
transformation from novice to competent practitioner.
We have subsequently created a Clinical Worksheet expressly designed to serve as a vehicle for capturing the learner’s
thoughts so that their clinical supervisors have a clear understanding of how the learner is working through the problem at
hand. We have constructed the worksheet to reveal what we believe to be important stages of the clinical problem solving
process: A) Recognizing and prioritizing patient problems, B) Listing, rank ordering and defending preliminary differentials
for the problem at hand, C) Listing the learner’s diagnostic impression and the ancillary technologies they believe are
needed to rule-in and rule-out their diagnostic impression, and D) Listing and defending treatment and management plans.
By utilizing this worksheet, clinical supervisors have an opportunity to study and reflect upon the results of the learner’s
workup and thereby, offer feedback and guidance sufficient to improve the learner’s evolving clinical competencies related
to the patient and problem at hand.
Following are instructions that should make clear how clinical supervisors can utilize the worksheet to improve the
learner’s clinical competencies.
A. Problem Recognition/Prioritization: An experienced clinician knows how to sift through the patient’s stated chief
complaint and presenting signs and symptoms to rapidly identify the ‘problem’ that will serve as the focus of their
workup. Unfortunately, learners don’t often make this distinction and will use the patient’s chief complain as the
starting point for their workup. It is critical that both the learner and clinical supervisor be at the same starting point.
Section ‘A’ of the worksheet requires that the leaner separately state the patient’s chief complaint (and its key
historical and physical findings) versus their perception of the ‘patient’s primary problem’ (and its key historical and
physical findings). By doing so, the worksheet helps assure that the learner and supervising clinician will be at the
same starting point. Upon review of the learner’s perception of the patient’s primary problem and associated key
historical and physical findings, what supervisor comments, feedback, guidance would likely improve the learner’s
ability to recognize and prioritize patient problems as distinct from chief complaints?
B.
Differentials for Patient’s Primary Problem: An experienced clinician knows the common and important differentials
to be considered for the vast majority of problems likely to present at their practice location. The clinician also knows
the characteristic clinical findings useful to confirm and differentiate one differential from another. However, medical
students are not likely to have a robust list of differentials for all of the problems they are likely to encounter during
any given clinical rotation nor do they fully comprehend how to use the patient’s signs and symptoms to clinically rule
in/rule-out (confirm and differentiate) those competing differentials. Residents are likely to have a more robust list of
differentials and a deeper comprehension of how to use signs and symptoms to confirm and differentiate competing
differentials but their clinical diagnostic skills can be refined when supervisors share with residents ‘how to weigh’
specific clinical findings to rule-in and rule-out competing differentials.
Section ‘B’ of our worksheet asks the learner to list the common and important differentials to be considered for their
patient’s primary problem. It also asks the learner to list what they believe to be the three leading differentials, and, to
identify the key confirmatory and discriminatory findings associated with each of their three leading differentials.
Upon review of the learner’s differentials and key clinical findings, what comments, feedback, guidance would
improve the learner’s knowledge of the problem’s key differentials, and, their comprehension of how to more
efficiently and effectively weigh key confirmatory and discriminatory findings to assist in the rule-in/rule-out process?
C.
Working Clinical Diagnosis: An experienced clinician knows how to utilize key diagnostic technologies to rule in/out
their leading diagnostic considerations and reach a working diagnostic impression. They also know how to utilize
diagnostic technologies in a cost and time efficient manner. Students and residents often feel the need to order
multiple diagnostic technologies with little consideration of their associated sensitivity, specificity and costs. This in
turn leads to costly workups and unnecessary delays in both initiating appropriate treatments and a management plan
for the patient.
Section ‘C’ of our worksheet asks the learner to declare their working clinical impression (preliminary diagnosis) and
then list the diagnostic technologies they feel are required to more conclusively rule-in or rule-out their clinical
impression. Upon review of the learner’s requested diagnostic impression and requested diagnostic technologies,
what comments, feedback, guidance would improve the learner’s efforts at cost containment in terms of diagnostic
technologies, sensitivity, specificity, etc in arriving at a cost and time efficient diagnosis?
D. Treatment/Management Plan:
Experienced clinicians also are sufficiently comfortable with their working clinical impression to initiate appropriate
preliminary or definitive treatment(s) and management plans before all the ancillary technology studies have been
returned. Learners are not as confident in venturing forth into treatment and management plans but the patient’s
disease etiology might require a working draft of treatment and management plans in the interim.
Section ‘D’ of our worksheet asks the learner to declare their preliminary treatment and management plans. Upon
review of the learner’s diagnostic impression, requested diagnostic technologies, treatment and management plans,
what comments, feedback, guidance would improve the learner’s treatment and management plans?
MOVING FORWARD: After reflecting upon your experiences with students and residents on clinical rotations, we now ask
you to consider whether this Clinical Worksheet represents an improved means of both expressing the learners thoughts
regarding any given patient workup, and, providing you an opportunity to study and reflect upon the lkearner’s evolving
clinical competencies. If you think the worksheet represents an improved means of working with learners, we now ask you
to consider using the worksheet.
In an ideal world, learners would utilize this worksheet on every patient encounter, while you in turn would utilize the
worksheet as a means of providing learners with the feedback and guidance they need to expedite their transformation
from novice to competent practitioner. However, we fully appreciate that this is not an ideal world. At this time we simply
ask that you consider using the worksheet on a once a day basis with each student on your rotations.
If you have questions, comments, feedback regarding our Clinical Worksheet, or it’s use with students and residents on
rotations with you, please feel free to email or call me.
Sincerely,
Frank Papa, DO, PhD
Professor, Medical Education
Associate Dean, Curricular Design and Faculty Development
UNTHSC
fpapa@hsc.unt.edu
office phone: 817.735.2528
Student / Patient Clinical Worksheet
Student Doctor:_________________ Rotation:____________________ DATE: __________________
A. Problem Recognition/Prioritization
Patient’s chief complaint:
Summary of Patient’s positive and negative historical findings:
Summary of Patient’s positive and negative physical findings:
Summary of Patient’s OMM findings:
In the following, state the ‘Patient Problem’ serving as the focus of today’s workup (ignore the following if the
patient’s chief complaint is the ‘problem’ for which you intend to perform today’s workup)
Today’s Primary Patient Problem:
Key Historical findings related to today’s primary problem:
Key Physical findings related to today’s primary problem:
Key OMM findings related to today’s primary problem:
B. Differentials for the Patient’s Primary Problem:
(List differentials and identify the front running differentials with asterisk)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Key clinically-derived supportive/confirmatory/discriminatory findings for working DDX #1:
Key clinically-derived supportive/confirmatory/discriminatory findings for working DDX #2:
Key clinically-derived supportive/confirmatory/discriminatory findings for working DDX #3:
C. Working Clinical Impression (Preliminary Diagnosis): __________________
Requested R/I - R/O diagnostic technologies (lab, radiologic, etc):
Labs:
Radiology:
Special Studies:
D. Treatment/Management Plan
Treatment Plan:
Management Plan: