Calibrated Peer Review Clinical Note Writing Tools
http://cpr.molsci.ucla.edu/cpr/cpr/login.asp
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Abbreviations
Common medical abbreviations are acceptable.
HISTORY: Include significant positives and negatives from history of present illness, past medical history,
review of system(s), social history, and family history.
PHYSICAL EXAMINATION: Include vital signs, general patient description, and indicate pertinent
positive and negative findings related to presenting issue.
ASSESSMENT
Synthetic Statement: Briefly summarize the patient’s presentation using semantic qualifiers.
Differential Diagnosis: In order of likelihood, write no more than 5 differential diagnoses for this patient’s
current problems.
1. _______________________________________
2. _______________________________________
3. _______________________________________
4. _______________________________________
5. _______________________________________
DIAGNOSTIC WORK UP: Immediate plans for no more than 5 further diagnostic studies. [If no results
were supplied for invasive physical examination maneuvers (pelvic exam, rectal exam, etc.), these should
be listed in the plan.]
1. _______________________________________
2. _______________________________________
3. _______________________________________
4. _______________________________________
5. _______________________________________
©2005 University of New Mexico School of Medicine, Assessment & Learning Programs
Revised 06/05/2007