3. IMPRESSION AND PLAN • Stated whether the management plan was discussed Provided diagnosis and/or differential diagnosis with patient • Provided a management plan Stated who would be responsible for elements of the • • Provided a rationale for the management plan management plan and follow-up • (education) Answered the referring physicians question (if present) • POOR BORDERLINE ACCEPTABLE GOOD EXCELLENT 1 2 3 4 5 Key issues not Most key issues All key issues addressed. identified and identified and Did not answer addressed. addressed. referring physician’s Answered Answered referring question. referring physician’s physician’s question. No rationale for question. Provided rationale for recommendations. No Some rationale for recommendations education provided. recommendations. made. No indication of who No education Provided education. will do what. provided. Clear plan for who Some indication of will do what and who who is is responsible for responsible for follow-up. management plan Noted what patient elements and was told. follow-up. STYLE 4. CLARITY AND BREVITY Length of sentences: • • Words used: one idea per sentence (less than 3 syllables) each sentence less than 3 lines long active voice Length of paragraphs: • minimal medical jargon; minimal filler words/phrases one topic per paragraph no word or phrase repetition each paragraph less than 4-5 sentences long POOR BORDERLINE ACCEPTABLE GOOD EXCELLENT 1 2 3 4 5 Wordy. Message Concise. Minimal Concise. Clear and unclear Redundant jargon and fillers. organized. words/phrases Lots Some active tone. No redundant of jargon and fillers. Some short words/phrases. Mostly passive tone. sentences. No jargon and fillers. Long sentences. Some sentences with Active tone primarily. Long paragraphs. one idea/sentence. Short sentences. Some short One idea/sentence. paragraphs. Short paragraphs. 5. ORGANIZATION OF LETTER Use of headings • Layout visually appealing with lots of white space • Use of bulleted or numbered tables, or graphics as appropriate • • Information easy to scan POOR BORDERLINE ACCEPTABLE GOOD EXCELLENT 1 2 3 4 5 No headings. Some headings used. Headings clear and No white space. Some white space. appropriate No bulleted or Some bulleted and Lots of white space. numbered lists. numbered lists. Numbered No tables. Generally easy to and bulleted lists. Difficult to scan. scan. Use of graphics or Most key info tables. easy to find. Very easy to scan.
3. IMPRESSION AND PLAN • Provided diagnosis and/or differential diagnosis • Provided a management plan • Provided a rationale for the management plan (education) • Stated whether the management plan was discussed with patient • Stated who would be responsible for elements of the management plan and follow-up • Answered the referring physicians question (if present) POOR 1 Key issues not addressed. Did not answer referring physician’s question. No rationale for recommendations. No education provided. No indication of who will do what. BORDERLINE 2 ACCEPTABLE 3 Most key issues identified and addressed. Answered referring physician’s question. Some rationale for recommendations. No education provided. Some indication of who is responsible for management plan elements and follow-up. GOOD 4 EXCELLENT 5 All key issues identified and addressed. Answered referring physician’s question. Provided rationale for recommendations made. Provided education. Clear plan for who will do what and who is responsible for follow-up. Noted what patient was told. STYLE 4. CLARITY AND BREVITY • Words used: (less than 3 syllables) active voice minimal medical jargon; minimal filler words/phrases no word or phrase repetition • Length of sentences: one idea per sentence each sentence less than 3 lines long • Length of paragraphs: one topic per paragraph each paragraph less than 4-5 sentences long POOR 1 Wordy. Message unclear Redundant words/phrases Lots of jargon and fillers. Mostly passive tone. Long sentences. Long paragraphs. BORDERLINE 2 ACCEPTABLE 3 Concise. Minimal jargon and fillers. Some active tone. Some short sentences. Some sentences with one idea/sentence. Some short paragraphs. GOOD 4 EXCELLENT 5 Concise. Clear and organized. No redundant words/phrases. No jargon and fillers. Active tone primarily. Short sentences. One idea/sentence. Short paragraphs. 5. ORGANIZATION OF LETTER • Use of headings • Layout visually appealing with lots of white space • Use of bulleted or numbered tables, or graphics as appropriate • Information easy to scan POOR 1 No headings. No white space. No bulleted or numbered lists. No tables. Difficult to scan. BORDERLINE 2 ACCEPTABLE 3 Some headings used. Some white space. Some bulleted and numbered lists. Generally easy to scan. Most key info easy to find. GOOD 4 EXCELLENT 5 Headings clear and appropriate Lots of white space. Numbered and bulleted lists. Use of graphics or tables. Very easy to scan.