PRIMARY CARE CLERKSHIP
Patient Encounter Form
Insert ID:
Encounter Date:
Patient Sex:
Female
Male
Return Visit:
Yes
No
Insurance:
Medicare
Medicaid
Private
HMO
Medicare/caid
Other
None
Choose Type
Location of Care:
Choose Location
Clinic
Pvt Office
Inpt
ER
Shelter
Home Visit
School
Nursing Home
Other
Visit Type:
Choose Type of Visit
General Check-up
F/u Chronic Illness
Sick Visit
Duration:
Choose Encounter Duration
<15 min
16 - 30 min
31 - 45 min
46 - 60 min
>60 min
Useful Feedback?
1-Low
2
3-Medium
4
5-High
Level of Participation
1-Low
2
3-Medium
4
5-High
Learning Value
1-Low
2
3-Medium
4
5-High
Primary Diagnosis:
Secondary Diagnosis:
(when applicable)
Tertiary Diagnosis:
(when applicable)