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iRubric: Student nurse narrative nursing note rubric

iRubric: Student nurse narrative nursing note rubric

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Student nurse narrative nursing note built by wcmcintosh

Rubric Code: AX9WBC2
Rubric designed to evaluate the end of clinical/shift note completed by level one nursing students
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Keywords: (None)
Categories: Subjects: Medical   Nursing  
Types: Assignment   Writing  
Grade Levels: Undergraduate

Powered by iRubric Narrative Note Grading Rubric
  Below Average
1 pts
Average
2 pts
Above Average
3 pts
Exceptional
4 pts
Subjective assessment is fully expl
Below Average

Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information is the main theme for the assessment
Average

Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.
Above Average

Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.
Exceptional

Subjective assessment of health status is fully developed and linked to the reason for presentation without including irrelevant information.
Assessment is fully developed and includes location, duration, timing, character, severity provocative/palliative factors and/or other features appropriate for the reason for presentation.
Note specific and detailed
Objective assessment is fully expli
Below Average

Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/or inappropriate for the presenting problem.
Average

Two or more elements needed for adequate evaluation of a patient's problem is missing from the subjective and/or objective assessment.
Above Average

Objective assessment is missing an element needed for adequate evaluation of the patient's problem.
Includes irrelevant information in assessment of head to toe evaluation
Exceptional

Objective assessment of health status is fully developed
Physical exam includes vital signs, height and weight and any relevant data related to full head to toe assessment of patient
Documentation is clear and well org
Below Average

Documentation does not meet expectations for this level as evidenced by either of the following:
lay terminology, illogical sequencing, missing essential elements.
Plagiarism noted from other health care provider notes.
Average

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence for head to toe documentation
but the reader is able to determine findings with difficulty.
Above Average

Documentation meets criteria for "exceptional" but there is occasional repetiton of workding or phrases. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for head to toe documentation but the reader is able to determine findings with minimal difficulty.
Exceptional

Documentation is clear and well organized.
Appropriate medical terminology is used.
Repetitious words or phrases are not utilized.
Format follows a standard. Narratives for head to toe and follow up notes have a logical flow.
First Morning Note
Below Average

Documentation does not meet expectations for this level as evidenced by either of the following: does not clearly state pt is alive at time of "first look", safety precautions in place, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism noted from other health care provider notes.
Average

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence for "first look" note and safety but the reader is able to determine findings with difficulty.
Above Average

Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for "first look" and safety documentation but the reader is able to determine findings with minimal difficulty.
Exceptional

Documentation is clear and well organized.
Appropriate medical terminology is used.
Repetitious words, phrases, and other distracting information are omitted. "first look" and safety format follows a standard and has a logical flow.
Focused Head to Toe Assessment
Below Average

Documentation does not meet expectations for this level as evidenced by either of the following: does not clearly show a head to toe assessment, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism noted from other health care provider notes.
Average

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence for focused head to toe note and safety but the reader is able to determine findings with difficulty.
Above Average

Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format for focused head to toe assessment and safety documentation but the reader is able to determine findings with minimal difficulty.
Exceptional

Documentation is clear and well organized.
Appropriate medical terminology is used.
Repetitious words, phrases, and other distracting information are omitted. Focused Head to toe assessment and safety format follows a standard and has a logical flow.
Follow up notes
Below Average

Incorrectly or fails to apply evidence-based guidelines to assesment, DX, plan, patient education, or follow-up. Does not meet expectations for this level as evidenced by either of the following: does not clearly show follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. Use of lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.<BR>
Plagiarism from other health care provider not
Average

Documentation meets criteria for clarity but needs to be better organized.<BR>
Documentation occasionally strays from standard format from logical sequence for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. The reader is able to determine findings with difficulty.<BR>
<BR>
Includes 2 or more errors in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or fol
Above Average

Documentation meets criteria for "exceptional" but there is occasional redundant/distracting info. Follow up plan is appropriate and meets above criteria but is "generic" occasionally strays from standard format for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. Includes only 1 minor error in the application or omission of evidence-based guidelines to assessment,DX,plan, patient education, or follow-up
Exceptional

Documentation is clear & well organized.
Appropriate medical terminology & phrases. Redundant words & other distracting info. are omitted. Follow up to pain, prn meds, urgent situations, or abnormalities in head to toe assessment follow a standard & has logical flow.
Plan is appropriate for the DX & accurately addresses the problem identified for eval/Follow up



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