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Chief Editor Vacancy
Created Aug 3, 2019
Last edited Aug 3, 2019
All contributors
Sharing policy Public
Edit policy Allowed
Organ system Other
Medical field
Patient population Adult, Pediatrics
Setting Inpatient, Outpatient
Type
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Chalk Talk
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    Contents

    Subjective

    Subjective


    Best practices
    Suggestions (not requirements):

    1. Your dotphrase can contain any/all of Subjective (S), Objective (O), Assessment/Plan (AP), Patient Info (PI), or Admin/Other (AO). It can address a known diagnosis or an undifferentiated complaint. Encourage focusing on Assessment/Plan since this is the most challenging and not many existing dotphrases cover this.

    2. Please include evidence where appropriate, e.g.:

    • for Subjective and Objective elements, cite likelihood ratios or sensitivity/specificity
    • for assessment/plan, cite NNT/NNH for treatments and/or clinical decision rules
    • cite references
    • include links to shared decision aids

    3. Write text in such a way as it can be directly used without editing, (eg, "The patient denied x, y, z" rather than "x, y, z?")

    4. If S/O/AP have significant branch points, (eg, micro/normo/macrocytic anemia), indicate that and write separate text that is appropriate to each with the understanding that the other branches' text can be deleted.

    5. For plans, try to include first, second and/or third line workup.

    Comments, questions or edits for this guide? Click here: Help:Tab General