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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 in Western Clinical Medicine Rubric Code: QX386X4 By orneryt Ready to use Public Rubric Subject: Nursing Type: Assessment Grade Levels: Graduate

Health and Physical Assessment
	Failing 0 pts	Fair 70 pts	Good 90 pts	Very Good 100 pts
Essential Tasks 10 pts 1. Introduces self 2. Identifies patient 3. Washes Hands 4. Determines existence of allergies, medications, herbal preps, etc check vital signs,record height and weight	Failing Students fails to perform 2 or more required tasks points:0-3	Fair performs tasks with 2 omissions points: 6-4	Good performs tasks with one omission points:9-7	Very Good Student performs all required tasks points:10
Obtain history 30 pts 1. Obtains the Chief Complaine 2. Asks the appropriate questions related to the the CC and expands the HPI 3. Gathers pertinent family,past present , social, religion work, habits	Failing Inadequate history taking, fails to gather pertinent positive negatives, ROS, or important PMHx, Social, etc. points:	Fair misses to gather pertinent history like when the surgery was done , any investigational drugs,recreational drugs points:	Good .gathers pertinent information ,misses one or two data points:	Very Good gathers complete pertinent history past , present medical and surgical component,social,reli gious,smoking habits points:
professional attitude 30 pts Effective professional communication orally and in writing.	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.