Introducing TOCSE: A Tool to Bridge Didactic Learning to Clinical Application (Part 2)

Target-Oriented Clinical Skill Enhancement (TOCSE): Part 2

Part 2 of TOCSE is geared towards 3rd year medical students preparing to be in the 4th year. It has the following important elements as follows:

  • Identifying clinical problems as targets to resolve.
  • Writing daily progress notes through S-O-A-P.
  • Writing the Assessment.
  • Formulating Plans according to assessment.
  • Constructing the TOCSE table.
  • Writing the Discharge Summary.

Qualifiers for Clinical Situations

Table 1 shows the qualifiers to describe clinical situations in progress notes.


Table 1. Qualifiers for clinical situations.

Sign or Symptom


Difficulty of breathing




Bipedal edema

+ to ++++

Cough, nausea, dizziness

Less or more

Capillary blood sugar



Hgb, Hct






+ to ++++, less or more

Blood pressure

Systolic and diastolic in mmHg

Writing Daily Progress Notes

Progress notes are a part of the medical record that accounts for a patient's course. It serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, and assisting in protecting the legal interest of the patient and the health care providers. It is a document utilized to communicate with colleagues and the health care team, the essentials of our patients' medical issues to help everyone provide the best care to the patient. It is simply a snapshot of what transpired during a patient's visit to a doctor.

Briefly, writing the progress notes follows a specific pattern:

  • It has S-O-A-P parts. S for subjective data, O for objective data, A for Assessment, and P for plan
  • Subjective Data changes according to whether the patient improves or worsens.
  • The results of the work-up go into the Objective Data. See Figure 1.
  • The changes in the physical examination findings also go into the Objective Data.
  • The combined data in the S and O are the basis for the Assessment.
Figure 1. Mapping scheme for writing progress notes.

Writing the Assessment

Writing the Assessment follows a certain format: 1) Comparing data from yesterday’s condition, 2) Giving the reason for the change, and 3) Prognostication of the patient’s condition, whether improving, stable, or worsening. The Assessment is the basis for the Plan. The Plan may remain the same or needs to be revised (Figure 2).

The Assessment is written in a paragraph form. Address all changes (signs, symptoms, physical examination findings) in the subjective and objective data with, more importantly, explanation of either the improvement or worsening of each clinical feature based on the management given.

Figure 2. Sample of Assessment.


Based on the Assessment above, understandably, in the Plans, the antihypertensive medication of the patient will be adjusted.

The TOCSE Table

The TOCSE Table has the following attributes (Table 2):

  • The TOCSE table is a summary of the patient's clinical course.
  • It clearly depicts the resolution of acute problems of the patient.
  • It shows a correlation of the course of acute problems with appropriate management.
  • It shows how the target outcome is achieved.
  • Data must come from daily progress notes.
  • The TOCSE table has the following parts: clinical, biochemical/laboratory, imaging, if any, and treatment.
  • Any new clinical problem is added accordingly.


Table 2. Sample of a TOCSE table.

CBG; capillary blood glucose, WBC; white blood cell count, OD, once a day, BID, twice a day, SC, subcutaneous

Writing the Discharge Summary

The Discharge Summary becomes short and brief because details are depicted in the TOCSE Table (Figure 3). It is ideal that the Discharge Summary and the TOCSE Table are given together to the patient upon discharge.

Figure 3. Sample of Discharge Summary.


The ultimate objective of TOCSE is to further develop and enhance the clinical skills of the students through understanding and application of knowledge on basic sciences like physiology, pharmacology, biochemistry, pathology, anatomy and pharmacology on signs and symptoms of the patient and hence bridging the gap to clinical application. This skill results in the ability to formulate a plausible diagnosis and comprehensive, practical and cost-effective management plan and eventual resolution of each targeted clinical problem. Figure 4 summarizes the whole concept of TOCSE.


Figure 4. Concept map of Target-Oriented Clinical Skill Enhancement (TOCSE).


CC BY: Open Access Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit