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Progress Note
Progress Note (DRAFT 2)
For use in quality review of psychiatric records.
Rubric Code:
UX8C5CX
By
lmyronuk
Ready to use
Public Rubric
Subject:
Medical
Type:
(Other)
Grade Levels:
Graduate, Post Graduate
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Outpatient Chart Review
Progress Note
Unacceptable
Red
0 pts
Needs improvement
Red
1 pts
Acceptable
Yellow
2 pts
Good
Green
3 pts
1. Subjective
Unacceptable
Absent
Needs improvement
Recorded for all visits but incomplete. Some required elements missing or difficult to decipher.
Acceptable
All required elements recorded for all visits. Detail is adequate but minimal.
Good
Notes are thorough and well written. Easy to decipher.
2. Objective
Unacceptable
Absent
Needs improvement
Recorded for all visits but incomplete. Some required elements missing or difficult to decipher.
Acceptable
All required elements recorded for all visits. Detail is adequate but minimal.
Good
Notes are thorough and well written. Easy to decipher.
3. Assessment
Unacceptable
Absent
Needs improvement
Recorded for all visits but incomplete, vague or non-specific.
Acceptable
Recorded for all visits. Detail is adequate but minimal.
Good
Recorded in detail for all visits, includes revision to DSM codes where appropriate.
4. Plan
Unacceptable
Absent. Management plan modifications not made when indicated.
Needs improvement
Plan modifications made, but not appropriately driven by patient response/outcome measurement.
Acceptable
Appropriately, timely modifications made in accordance with patient response/outcome measurement.
Good
Evidence of constant attention to plan modification as indicated for optimal response. Evidence of appropriate transition from passive to active care.
Keywords:
file, chart, quality, review, psychiatry
Subjects:
Medical
Types:
(Other)
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