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iRubric: Clinical File Review DRAFT 7/29/09 rubric

iRubric: Clinical File Review DRAFT 7/29/09 rubric

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Clinical File Review DRAFT 7/29/09 Clinical File Review For use in quality review of chiropractic clinical records. Rubric Code: E3XA94 By JP_NYCC Ready to use Public Rubric Subject: Medical Type: (Other) Grade Levels: (none)

DC File Review Clinical File Review
	Very poor Red 0 pts	Unacceptable Red 1 pts	Acceptable Yellow 2 pts	Good Green 3 pts	Exceptional Blue 4 pts
1. Informed consent	Very poor Non-compliant	Unacceptable This rating not available for this item.	Acceptable This rating not available for this item.	Good Compliant	Exceptional This rating not available for this item.
2. Privacy Practice	Very poor Notification not documented	Unacceptable This rating not available for this item.	Acceptable This rating not available for this item.	Good Notification documented	Exceptional This rating not available for this item.
3. History	Very poor Does not address chief complaint.	Unacceptable Lacks significant required data.	Acceptable Sufficient to understand chief complaint but not comprehensive.	Good History of chief complaint very well done. All aspects of history meet expectations.	Exceptional Excellent history in all respects. Exceeds expectations.
4. Clinical Exam	Very poor Does not demonstrate an understanding of the patient's complaint or history.	Unacceptable Exam insufficient for diagnosis and/or management.	Acceptable Sufficient for diagnosis and management of the chief complaint.	Good Comprehensive examination meets expectations in all respects.	Exceptional Excellent examination. Exceeds expectations.
5. Advanced Testing Diagnostic imaging and other advanced testing.	Very poor Indicated testing not ordered or testing ordered was inappropriate.	Unacceptable Testing was ordered, but objectives could have been accomplished in a manner more accurate, less invasive, less expensive, quicker, or more convenient.	Acceptable Testing adequate for diagnosis and management, but better choices could have provide better quality data.	Good Testing was appropriate in light of DDx and there is clear evidence that best use was made of all information gained.	Exceptional Testing was optimal in all respects
6. Diagnosis	Very poor Diagnosis inconsistent with findings and/or problem list is not current.	Unacceptable Diagnosis is supported by findings, but does not account for all available data.	Acceptable Diagnosis is consistent with findings and provides an adequate basis for management.	Good Diagnosis accounts for all significant findings.	Exceptional All aspects of the diagnosis are completely consistent with available data and are expressed to the highest level of understanding.
7. Tx Plan	Very poor Plan is missing or inconsistent with diagnosis.	Unacceptable Plan is incomplete and/or unlikely to achieve desired outcomes.	Acceptable Plan is appropriate with regard to the chief complaint but does not address co-morbidity.	Good Plan appropriately addresses all diagnosed conditions.	Exceptional Plan appropriately addresses all diagnosed conditions and seeks to optimize patient's well-being.
8. Self-care	Very poor No self-care recommended.	Unacceptable Recommended self-care is unlikely to be effective.	Acceptable Self-care recommended is likely to be effective with regard to the chief complaint.	Good Self-care recommended is likely to be effective with regard to all aspects of the patient's condition.	Exceptional Self-care recommended is likely to be effective with regard to all aspects of the patient's condition and there is evidence of appropriate follow-up and adjustment as indicated.
9. Management Goals	Very poor Goals missing or inconsistent with diagnosis.	Unacceptable Goals appropriate to diagnosis, but unrealistic with regard to degree or time.	Acceptable Goals are appropriate to diagnosis and are realistic.	Good Goals are appropriate to diagnosis and are realistic. There is evidence of patient involvement in goal-setting.	Exceptional There is evidence that discussion of progress toward goals is a consistent aspect of doctor/ patient communication.
10. Outcome Measures	Very poor Missing or inappropriate.	Unacceptable Difficult to measure accurately. Do not fully indicate level of progress. May be unreliable.	Acceptable Adequate indicators of progress toward goals related to chief complaint.	Good Good indicators of progress toward all diagnosed conditions are included.	Exceptional Indicators of progress toward optimum well-being are included.
11. Plan Modification	Very poor Management plan never modified or modification is inconsistent with or unsupported by available data.	Unacceptable Modifications were made when indicated but are unlikely to improve patient response to care.	Acceptable Appropriate modifications made in a timely manner and are likely to improve response.	Good Evidence of constant attention to modification of treatment plan as indicated for optimum response.	Exceptional Modifications of treatment plan show evidence of patient involvement and buy-in.
12. Management Benefit	Very poor Undocumented	Unacceptable Some documentation, but not consistently expressed in terms of predetermined goals and outcome measures.	Acceptable Documentation of benefit with regard to chief complaint considers predetermined goals and outcome measures.	Good Comprehensive documentation of benefit regarding all diagnosed conditions considers predetermined goals and outcome measures.	Exceptional Includes documentation of benefit with regard to progress toward optimum well-being.
13. Progress Notes	Very poor Missing or not in required format.	Unacceptable Notes recorded for all visits but are incomplete. Some required elements missing.	Acceptable All required elements present for all visits. Detail is adequate for effective case management.	Good Notes are comprehensive and exceptionally well written. Few or no grammatical errors.	Exceptional The chart is a professional liability defense attorney's dream!
14. Legibility	Very poor Unreadable	Unacceptable Mostly readable with difficulty. Some words can not be made out.	Acceptable Completely readable with some difficulty.	Good Easily read.	Exceptional Electronic health record.

Keywords:

file, chart, quality, review

Subjects:

Medical

Types:

(Other)

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