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Clinical Case Study 
Clinical Case Study
This rubric is designed to evaluate History Taking skill assignment for the beginning NP students. It should show comprehensive history taking skills reflecting the class lectures and readings.
Rubric Code: JX8A29W
By juliaknauff
Ready to use
Public Rubric
Subject: Nursing  
Type: Assessment  
Grade Levels: Graduate

Powered by iRubric I. Health History
  Unacceptable-redo <7.0

(N/A)

Marginally Acceptable: 7.5

(N/A)

Satisfactory for now:8.0-9.0

(N/A)

Well done: >9.0

(N/A)

Chief Complaint (CC) and HPI

Unacceptable-redo <7.0

Chief Complaint and History of Present Illness is scant. The majority of vital information to the chief complaint is missing.
Remediation Required. can't tell the major reason why the pt is with the clinician
Marginally Acceptable: 7.5

Chief Complaint and History of Present Illness description is missing some vital information relevant to the chief complaint.
Satisfactory for now:8.0-9.0

Chief Complaint and History of Present Illness description is appropriate for the most part. Some non-vital information relevant to chief complaint is missing. OPQRSTAA or OLDCART are not well utilized, modified, or self-checked as appropriate.
Well done: >9.0

Chief Complaint and History of Present Illness is complete and age and gender appropriate. It is written in a logical format self checking with major components learned in class. Some relevant information of the pt's medical history is appropriately weaved into the present illness description. Theme of the HPI is clear with a good picture of pt's problem presented.
Complete Review of Systems (ROS)

Unacceptable-redo <7.0

Complete Review of Systems is missing.<BR>
<BR>
Remediation Required
Marginally Acceptable: 7.5

Components of a complete Review of Systems are missing or poorly addressed:
Satisfactory for now:8.0-9.0

Complete Review of Systems are covered but vaguely addressed. Relevant ROS systems related to CC and HPI need more description.
Well done: >9.0

A complete Review of Systems is present. Positives and Negatives of pertinent ROS is well described supporting or non-supporting the pt's HPI as needed.
Past Medical History I (PMH)

Unacceptable-redo <7.0

Complete Past Medical History is missing.<BR>
<BR>
Remediation Required
Marginally Acceptable: 7.5

Past Medical History is incomplete. Given information is not adequate in providing good assessment of the patient presented. There are some key components missing from: Childhood illnesses; Adult medical illnesses; Surgeries, OB/GYN; Psychaitric illnesses. The year of diagnosis and treatment is included if known.
Satisfactory for now:8.0-9.0

Past Medical History complete however there are some minor missing components.
Well done: >9.0

A complete Past Medical History is present and contains: Childhood illnesses; Adult medical illnesses; Surgeries, OB/GYN; Psychaitric illnesses. The year of diagnosis and treatment is included if known.
Overall documentation

Unacceptable-redo <7.0

unacceptable as a medical document
Remediation Required
Marginally Acceptable: 7.5

Unclear as to the major theme of the patient's problem presented. Writing is too detailed and not logically narrated.
Satisfactory for now:8.0-9.0

All assessment components present with show of good effort but writing is either too detailed or too robotic or with many grammatical errors in presentation for proper medical documents.
Needs improvement in future SOAP notes documentation.
Well done: >9.0

A complete history is presented regarding current CC/HPI, medication and allergies,
medical history, personal social history, family history and complete ROS are well written in logical format with a good flow. The Information presents well written health assessment documentation for this stage of learning.
Family and Social history

Unacceptable-redo <7.0

FHX and SHX information is missing.
Marginally Acceptable: 7.5

Family Social history is present but superficial and non related to patient concerns or care.
Satisfactory for now:8.0-9.0

Satisfactory content; writing needs improvement
Well done: >9.0

Satisfactory



Keywords:
  • Nurse Practitioner



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