Quantitative recording of physician clinical estimates, beyond a global estimate and formal joint count, in usual care: applying the scientific method, using a simple one-page worksheet.

摘要

Little attention has been directed to quantitation of clinical impressions and estimates of physicians. This article describes a one-page worksheet for completion by the physician at each patient visit. It includes a physician global estimate and estimate of change in status and four quantitative estimates for the degree of inflammation, degree of organ damage, and degree of fibromyalgia or somatization. An estimate of prognosis is recorded, with no therapy and with available therapies. All changes in medications are recorded. A template is available for a formal 42 joint count. The worksheet requires fewer than 15 seconds and has proven of considerable value in clinical care.