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iRubric: History and Physical Assessment rubric

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History and Physical Assessment History and Physical Assessment History and Physical of patient Rubric Code: BXW586A By wesmdg Ready to use Public Rubric Subject: Medical Type: Exam Grade Levels: Graduate

Health and Physical Assessment
	Failing 0 pts	Fair 50 pts	Good 60 pts	Very Good 75 pts
General Physical Assessment 50 % 1. Obtains the Chief Complaint 2. Asks the appropriate questions related to the the CC and expands the HPI 3. Gathers pertinent past medical history, ROS, Family, Psychosocial 4. Performs Physical Exam Using the appropriate techniques a. Inspection b. Palpation c. Percussion d. Auscultation	Failing Inadequate history taking, fails to gather pertinent positive negatives, ROS, or important PMHx, Social, etc. Inadequate assessment performed	Fair Student performs marginally effective assessment	Good Student performs efficient assessment of assigned body system with minor omissions in technique, teaching, or performance.	Very Good Student performs efficient assessment of assigned body system covering all gradable points with no omissions and is able to answer all questions posed by instructor or patient. Student also provides effective patient teaching during designated time limit.
Reporting 40 % Report should have following components: SUBJECTIVE 1. Biographical Sketch 2. Chief complaint or reason for visit 3. Patient Hx using initals and no identifying number 4. Previous illnesses and/or surgeries 5. Review of System OBJECTIVE 1. Results of physical exam. 2. Any followup action plan or tests	Failing Students report is inadequate with gross deficiencies	Fair Student fails to address all elements in detail during presentation	Good Student addresses all key elements	Very Good Student effectively correctly addresses every key element of the assessment
Communication 10 % Effective professional communication	Failing Failure to communicate .	Fair Student does not explain assessment to patient or talks minimally to patient	Good Student explains the assessment as they are completing each step.	Very Good Student explains the assessment as they are completing each step and is able to answer with confidence all patient questions in a calm and efficient manner.