UNM-SOM Clinical Note Global Grading Template
History
General
1
PE
4
5
6
7
8
9
10
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Adequate documentation of symptoms & findings
Similar data grouped together
Adequate congruence between symptoms, findings and
assessment and plan
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Clear portrayal of symptoms & findings
Recorded in logical sequence
Similar data grouped and labeled
Clear, explicit and correct congruence between
symptoms, findings and assessment and plan

Significant/critical symptom information
omitted
One or more essential positive and negative
elements of the history omitted
Significant erroneous information included.
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Symptom information is presented with necessary detail
Most of the pertinent positive and negative elements of the
history included.

Complete symptom information presented with
advanced level of detail (i.e. risk factor
assessment, well-characterized pain assessment)
All pertinent positive and negative elements of
the history included
Vital signs and/or general description of patient
omitted
Physical examination information is presented in
inadequate detail
Body systems noted that do not derive from
patient history
Essential body system(s) omitted
Significant positive & negative findings omitted
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Assessment
3
Vague or confusing wording/documentation
Information poorly organized
Significant incongruence between symptoms,
findings and assessment and plan
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Plan
2
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Vital signs and general description of patient included
o (If omitted, there are no important omissions in other
areas of the note)
Documents physical examination findings of appropriate
body systems
Includes documentation of most of the significant positive
and negative findings
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Vital signs and general description of patient
included
Documents physical examination findings from
pertinent body systems, coherent with history, in
appropriate detail
Includes all significant positive and negative
findings
Assessment Synthesis:

Absent or mere reiteration of history & findings
Interpretation of Data:

Differential diagnosis omitted (0 or only 1
diagnosis)

Differential contains highly unlikely diagnoses

Diagnoses inconsistent with Hx and PE findings
Assessment Synthesis:

Accurately reflects clinical situation but few appropriate
semantic qualifiers
o (If omitted, there are no important omissions in other
areas of the note)
Interpretation of Data:

Differential diagnoses reasonable but may be
inappropriately rank ordered, too narrow or excessively
broad in scope
Assessment Synthesis:

Succinct summary accurately and
comprehensively reflects clinical situation using
appropriate semantic qualifiers
Interpretation of Data:

Differential diagnoses in correct rank order

DDx comprehensive but appropriately targeted

DDx includes any serious illness with effective
intervention, albeit less common
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Plan omitted
Plan inconsistent with history, physical findings,
or differential
Plan could result in patient harm
Ambiguous or nonspecific plan items
Extraneous or unnecessarily expensive
recommendations included.
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Plan generally consistent with the history, physical findings
and differential
Evaluation plan insufficiently detailed before moving to
therapy items
Recommended interventions will not result in unnecessary
harm
Avoids most non-indicated diagnostic tests
Suggests indicated diagnostic tests which demonstrate
consideration of cost containment
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Well organized plan, clearly congruent with
patient history, physical findings and differential
Maximal use of well chosen, precisely targeted,
cost effective evaluations and interventions
Minimally invasive but optimally informative
evaluations
©2005 University of New Mexico School of Medicine, Assessment & Learning Programs, Revised 06/05/2007