Patient Info
Patient Initials: Gender:
Age Range: Ethnicity:
Visit Info
Minutes: Client Complexity:
Student Level of Function: Comfort Assessment
100% student Episodic (Acute condition)
75% student/ 25% preceptor Multiple/chronic/controlled disease
50% student/ 50% preceptor Multiple/chronic/uncontrolled
disease
25% student/ 75% preceptor Single/chronic/controlled disease
0% student/ observation only Single/chronic/uncontrolled disease
Wellness screening/HPDP
Immunizations
Type of Site: Type of Visit:
Follow-up: Acute/Episodic Care Pre-employment
physical
Chronic Illness Management Prenatal Visit
DOT Physical School Physical
Family Planning Visit STD/STI Visit
Health Maintenance Office Visit Well-child exam
Immunizations Well-woman exam
IUD Placement/Check
Menopause counseling
New OB visit
Other
Postpartum visit
,Type of Diagnostics: Ordering Diagnostics:
NA
Cardiopulmonary
Laboratory
Other
Radiology
Screening Tools
Procedures: Medications:
Therapeutics:
Education:
Physical Exam:
Coding
Diagnosis:
, Competencies
Skills & Procedures:
Notes:
Patient 2:
Patient Info
Patient Initials: Gender:
Age Range: Ethnicity:
Visit Info
Minutes: Client Complexity:
Student Level of Function: Comfort Assessment
100% student Episodic (Acute condition)
75% student/ 25% preceptor Multiple/chronic/controlled disease
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