| Category | Item | Value | Tally |
| Client Information | Site | Inpatient hospital | |
| ICU | |||
| Office | |||
| Nursing home | |||
| Subacute Inpatient | |||
| Long Term Care | |||
| Age | < 1 year | ||
| 1–3 years | |||
| 4–5 years | |||
| 6–9 years | |||
| 10–12 years | |||
| 13–18 years | |||
| 19–21 years | |||
| 22–64 years | |||
| 65+ years | |||
| Sex | Male | ||
| Female | |||
| Visit Information | Student Level of Function | Intense supervision – Level 1 | |
| Some Supervision – Level 2 | |||
| Joint Care – Level 3 | |||
| Mostly Independent – Level 4 | |||
| Independent – Level 5 | |||
| Practice Management | Level of visit/phys. exam | New acute visit – 99203 | |
| Acute office – 99213 | |||
| Chronic office – 99212 | |||
| New hospital – 99222 | |||
| Subsequent hospital – 99232 | |||
| New subacute – 0194 | |||
| Subsequent subacute – 0193 | |||
| New ICU – 99292 | |||
| Subsequent ICU – 99291 | |||
| ER – 99284 | |||
| OB – 99213 | |||
| Post Partum – 99212 | |||
| Delivery – 59409 | |||
| Health supervision for newborn under 8 days old – V20.31 | |||
| Health supervision for newborns 8 to 28 days old – V20.32 | |||
| Routine infant or child health check – V20.2 | |||
| Infant (younger than 1 year) well visit – 99381 | |||
| Early childhood (age 1–4 years) well visit – 99382 | |||
| Late childhood (age 5–11 years) well visit – 99383 | |||
| Adolescent (age 12–17 years) well visit – 99384 | |||
| Adult (18 years or older) well visit – 99385 | |||
| Diagnosis | 1 | ||
| 2 | |||
| 3 | |||
| 4 | |||
| Procedure | 1 obs asst perf N/A | ||
| 2 obs asst perf N/A | |||
| 3 obs asst perf N/A | |||
| 4 obs asst perf N/A | |||
| Student treatment plan and notes |
|||
| IV Medication | 1 managed monitored Not applicable | ||
| 2 managed monitored Not applicable | |||
| 3 managed monitored Not applicable | |||
| 4 managed monitored Not applicable | |||
| 5 managed monitored Not applicable | |||
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