(Please Read the Instructions thoroughly!)
Project
The student will be given a medical condition or disease.
You will have to research it to come up with enough information to write a detailed note as described below.
Must be in PQRRRST format and have specific notes for each part of the acronym.
Chief Complaint and PMH must add up to a minimum of 55 words.
1. Chief Complaint: Must be a minimum of 30 words (abbreviation included)
2. Past Medical History: Must be a minimum of 25 words
3. Medications: You must have medications associated with your disease and the proper dosages and two others with the proper dosages associated with the PMH.
4. Allergies: Must have 4 allergies:
a. 2 Medication
b. 1 Environmental
c. 1 Food
You will be graded on:
1. Accuracy of the note.
2. Proper medications and dosages for the disease are given.
3. Proper format. (PQRST)
Chart Note Project Rubric
Student Name: _______________________________________ Date: ______________
Disease/Condition Given: __________________________________________________
Chief Complaint:
Minimum of 30 words 15 Points _________
Provocation 5 Points _________
Quality 5 Points _________
Radiation 5 Points _________
Relief 5 Points _________
Reassurance 5 Points _________
Severity 5 Points _________
Time 5 Points _________
Total this section: 50 Points _________
Past Medical History:
Minimum 25 Words 20 Points _________
Total this section: 20 Points _________
Medications:
Medication applicable to Disease/Condition given 5 Points _________
Dosages Correct 5 Points _________
2 other medications associated with PMH with
proper dosages 5 Points _________
Total this section: 15 Points _________
Allergies:
2 Medication Allergies 4 Points _________
1 Environmental Allergy 4 Points _________
1 Food Allergy 4 Points _________
Total this section: 12 Points _________
All four components are in place and the proper order: 3 Points _________
Final Grade 100 Points _________
EXAMPLE:
Chart Note Project
On
Peptic Ulcer Disease
Submitted By:
………………………………………..
Mildred Elley NYC Metro Campus
SPECIALIZED PROCEDURE
MA 210-MV
Summer 1 / 2024
CHIEF COMPLAINT: Burning pain, and discomfort in the belly, vomiting, and lack of appetite
PROVOCATION: Discomfort and burning pain starts while eating food (any kind of food)
QUALITY: Burning pain
REGION: In the stomach from the belly to the breastbone
RELIEF: The burning sensation is relief when taken antacid for a few minutes to a couple
of hours
RADIATION: There is no radiation
Severity: Severe 6 out of 10 on a scale from 1 to 10
TIME: Starts at different times while eating
PAST MEDICAL HISTORY:
Started smoking in 1980
Excessive alcohol use in 2000
Emotional stress in 2010
MEDICATION:
MEDICATION APPLICATION TO DISEASE:
Omeprazole (Prilosec), Iansoprazole (Prevacid), Rabeprazole (Aciphex),
Esomeprazole (Nexium), Pantoprazole (Protonix)
CORRECT DOSAGES:
Omeprazole – 20 mg orally once a day for 4 weeks
Lansoprazole – 30 mg orally bid for 10 to 14 days
Rabeprazole – 20 mg once daily, provider will provide information.
Esomeprazole – 20 ng to 40 mg taken once per day, for 4 to 8 weeks
Pantoprazole – 40 mg taken once daily, with or without food for 8 weeks
OTHER MEDICATIONS ASSOCIATED WITH PROPER DOSAGES
Clarithromycin – 500 mg bid, Amoxicillin – 1 g bid (both twice a day for 10 days)
ALLERGIES
MEDICATION ALLERGIES – Penicillin and cephalosporin
ENVIRONMENTAL ALLERGIES – Dust
FOOD ALLERGIES – peanut
