OSCE Post-Encounter Note Scoring Rubric
Criterion 1: Chief concern of chest pain
Status: Included
Justification: The note clearly states “45yo m presents with shortness of breath due to intermittent chest pain.” While shortness of breath is mentioned first, chest pain is explicitly identified as part of the presenting complaint.**
Criterion 2: Episodic pattern of symptoms
Status: Included
Justification: The note describes “intermittent chest pain” and specifies that “the pain more noticable on exertion this morning (walking up stairs),” which indicates an episodic pattern with exertional triggers.**
Criterion 3: Poorly controlled history of hypertension
Status: Included
Justification: The note explicitly states “Hypertensive, although on medication, suggesting it is poorly controlled,” which directly addresses both the history of hypertension and its poor control status.**
Criterion 4: Vitals indicate hypertension
Status: Not Included
Justification: While the note mentions the patient is hypertensive, there is no documentation of actual vital sign measurements (e.g., specific blood pressure readings) to support this finding.**
Criterion 5: Pain radiates to the back
Status: Not Included
Justification: There is no mention of pain radiation to the back or any other location in the note.**
Criterion 6: Likely diagnosis of acute coronary syndrome (ACS), NSTEMI, or STEMI
Status: Included
Justification: The note states “Diagnostic testing to rule out ACS should be completed first,” which indicates ACS is being considered as a likely diagnosis requiring immediate evaluation.**
Summary: 4 of 6 criteria met ** Constructive Feedback**
Your clinical documentation demonstrates several strengths, particularly in capturing the essential presenting complaint and relevant medical history. You clearly identified both the chest pain and shortness of breath, recognized the episodic and exertional nature of the symptoms, and appropriately documented the patient’s poorly controlled hypertension despite medication use. Most importantly, you correctly prioritized acute coronary syndrome (ACS) in your differential diagnosis and appropriately indicated the need for immediate diagnostic testing to rule out this life-threatening condition. However, there are two critical gaps in your documentation that significantly limit the completeness of your clinical assessment. First, you failed to document the actual vital sign measurements, particularly the blood pressure reading that would objectively demonstrate the degree of hypertension present during this acute presentation. Second, you did not document whether the chest pain radiates to the back or any other location—a key characteristic that was presumably elicited during your history-taking.
These omissions have important clinical implications for this patient presenting with chest pain. Documenting specific vital signs, especially blood pressure values, is essential because the degree of hypertension can help differentiate between diagnoses (such as hypertensive emergency, aortic dissection, or ACS) and guides immediate treatment decisions, including whether antihypertensive therapy should be initiated or adjusted during the acute presentation. The pattern of pain radiation is equally critical in this scenario—radiation to the back is a red flag symptom for aortic dissection, a catastrophic condition that can mimic ACS but requires completely different management. Administering thrombolytics or anticoagulation for presumed ACS in a patient with unrecognized aortic dissection could be fatal. In emergency presentations with chest pain, these specific details aren’t just documentation formalities; they are essential data points that directly impact your differential diagnosis, determine which diagnostic tests are ordered, and influence potentially life-saving treatment decisions. Always document objective measurements and specific symptom characteristics to ensure safe, appropriate care. * Analysis of Feedback and Instructional Gaps
Pattern Analysis
This feedback reveals systematic instructional gaps rather than simple student oversight. The student demonstrated strong clinical reasoning (correctly prioritizing ACS, recognizing the need for immediate testing) but failed to document two fundamental clinical elements:
- Objective vital sign values (specific BP measurements)
- Critical symptom characteristics (pain radiation pattern)
The disconnect between good clinical thinking and incomplete documentation suggests students may not fully understand: - Which specific data elements are non-negotiable in documentation - Why certain details have life-or-death clinical implications - How documentation directly drives differential diagnosis refinement
This pattern indicates students are learning clinical reasoning but not the parallel skill of translating clinical assessment into complete, actionable documentation.
Curricular Recommendations
*Recommendation 1: Create a “High-Stakes Documentation Checklist” Resource**
Component to enhance: Pre-assignment resources and rubric materials**
Specific content: Develop a symptom-specific documentation checklist for common chief complaints (chest pain, shortness of breath, abdominal pain, headache). For chest pain specifically, create a visual checklist highlighting:** - Mandatory vital signs with rationale (BP values → differentiates dissection/hypertensive emergency) - Critical symptom descriptors (radiation pattern → rules in/out dissection) - “Cannot proceed without” documentation elements marked distinctly
Why this addresses the gap: Students need explicit guidance on which elements are clinically mandatory versus supplementary. The feedback shows the student captured history but missed critical specifics—a checklist bridges the gap between “taking a history” and “documenting decision-critical details.” This makes implicit expectations explicit.**
*Recommendation 2: Integrate “Documentation Consequences” Case Scenarios**
Component to enhance: Lecture content and practice cases**
Specific content: Add 2-3 brief case vignettes demonstrating adverse outcomes from incomplete documentation:** - Case A: Chest pain documented without radiation pattern → aortic dissection missed, anticoagulation given, patient deteriorates - Case B: “Elevated BP” documented without values → treatment delayed, hypertensive emergency progresses
Follow each vignette with guided reflection: “What specific documentation element was missing? What was the clinical consequence? How does this change your documentation approach?”
Why this addresses the gap: The feedback emphasizes clinical implications, but students may not viscerally understand the connection between documentation omissions and patient harm. Concrete examples of “what goes wrong” when specific elements are missing transforms documentation from a bureaucratic task to a patient safety imperative.**
*Recommendation 3: Add “Documentation Translation” Practice Exercises**
Component to enhance: Practice cases with structured feedback**
Specific content: Provide 3-4 practice scenarios where students receive a clinical vignette with complete information, then must:** 1. Identify which elements are “mandatory to document” vs. “supplementary” 2. Write the documentation 3. Receive immediate feedback comparing their documentation against an expert exemplar with annotations explaining why each element matters clinically
Include specific practice with vital sign documentation (writing actual values, not interpretations) and symptom characterization (specific descriptors, not generalizations).
Why this addresses the gap: This student likely heard the information during history-taking but didn’t recognize it as documentation-critical. Deliberate practice in translating clinical data into complete documentation—with immediate feedback—builds the habit of capturing specific, actionable details rather than general impressions.**
Context Considerations
Foundational knowledge requiring reinforcement: - Documentation of objective measurements (vital signs as numbers, not interpretations) - This is basic clinical documentation but may need explicit re-teaching in the context of decision-making
Clinical reasoning skills requiring additional practice: - Connecting specific documentation elements to differential diagnosis refinement (e.g., pain radiation → changes DDx from ACS alone to ACS vs. dissection) - Understanding documentation as a clinical reasoning tool, not just a record-keeping task
Advanced concept needing more emphasis: - The concept of “red flag symptoms” and their documentation priority - How specific details change management pathways (dissection vs. ACS requiring opposite treatments)
Implementation Priority
Immediate action: Implement Recommendation 1 (checklist) before the next assignment—low effort, high impact.**
Short-term: Develop Recommendation 3 (practice exercises) for ongoing skill-building.**
Curriculum revision: Integrate Recommendation 2 (consequence cases) into core lecture
