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iRubric: Health History and Physical Assessment rubric

iRubric: Health History and Physical Assessment rubric

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Health History and Physical Assessment 
Health History and Physical Assessment
Rubric Code: DX63WAW
By ccollins0131
Ready to use
Public Rubric
Subject: Nursing  
Type: Assignment  
Grade Levels: Undergraduate

Powered by iRubric Comprehensive Health Assessment
  0

0 pts

2

2 pts

4

4 pts

6

6 pts

Score

(N/A)

Part I-Biographical Data
6 pts

Includes all pertinent objective data
0

Student provides no biographical information.
2

Student provides less than 5 items of biographical data.
4

Student provides 5 to to 7 items of biographical data.
6

Student includes all elements of biographical data.
Score
Part 1-Continued
  0

0 pts

4

4 pts

8

8 pts

12

12 pts

Score

(N/A)

Reason for Seeking Care
12 pts

Provides clearly written explanation for patient appointment
0

Fails to provide a focused written statement for reason/feelings about seeking care.
4

Provides a vaguely written statement for reason/feelings about seeking care.
8

Provides a clearly written statement for reason/feelings for and about seeking care.
12

Provides a focused clearly written statement regarding the patient reason/feelings for and about seeking care. Places reason in quotations.
Score
History of Present Health Concern
12 pts

Includes comprehensive subjective data
0

Documentation is inadequate with >8 deficiencies in spelling and/or formatting(word usage).
4

Documentation fails to address all elements in detail or has 5-7 spelling, and /or word usage errors.
8

Documentation addresses all elements with 3-4 spelling, or word usage errors.
12

Documentation correctly addresses every element of the assessment having the proper format with <2 spelling, or word usage errors.
Score
Medical Health History
12 pts

Includes comprehensive health history data
0

Documentation is inadequate with >8 deficiencies in spelling, and/or word usage.
4

Documentation fails to address all elements in details or has 5-7 spelling, and or word usage errors.
8

Documentation addresses all key elements with 3-4 spelling, or word usage errors.
12

Documentation correctly addresses every key element of the assessment having the proper format with <2 spelling or word usage errors.
Score
Lifestyle
12 pts

Includes comphrehensive lifestyle data
0

Documentation is inadequate with >8 deficiencies in spelling, and or word usage.
4

Documentation fails to address all elements in details or has 5-7 spelling, and /or word usage errors.
8

Documentation addresses all key elements with 3-4 errors, spelling, and/or word usage errors.
12

Documentation correctly addresses every key element having the proper format with <2 spelling or word usage errors.
Score
Part II-Prevention and Maintenance
  0

0 pts

2

4 pts

4

6 pts

6

8 pts

Score

(N/A)

Part II-Prevention and Maintenance
12 pts

Lists learning needs based on health history and identified needs. Prioritizes list.
0

Student provides no recommendations.
2

Student provides one recommendation.
4

Student provides at least 2 prioritized recommendations.
6

Student provides at least 3 prioritized recommendations.
Score
Part III-Physical Assessment(ROS)
  0

0 pts

12

12 pts

24

24 pts

34

34 pts

Score

(N/A)

Part III-Physical Assesment(ROS)
34 pts

Assess all systems appropriately using inspection, palpation and auscultation as indicated. Appropriately assess all negative findings.<BR>
Document all findings concisely using appropriate terminology.
0

Student provides no physical examination documentation.
12

Student provides minimal physical examination documentation with 5-7 spelling or word usage errors.<BR>
No evidence of further assessment of negative findings.
24

Student provides adequate physical examination documentation that covers majority of systems with 3-4 spelling or word usage errors.<BR>
Evidence of appropriate assessment of negative findings documented.
34

Student provides adequate physical examination documentation that covers all systems using inspection, palpation, auscultation as appropriate with <2 grammatical, spelling or word usage errors.<BR>
Evidence of appropriate assessment of negative findings documented.
Score






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