iRubric: Consult: Objective Assessment rubric

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Consult: Objective Assessment Clinical Examination Appropriate DRAFT -2- For use in quality review of psychiatric records. Rubric Code: VX8B868 By lmyronuk Ready to use Public Rubric Subject: Medical Type: (Other) Grade Levels: Graduate, Post Graduate

Outpatient Chart Review Mental Status Examination
	Unacceptable Red 0 pts	Acceptable Yellow 2 pts	Good Green 3 pts
1. General appearance Picture in words; habitus, grooming, dress, speech, psychomotor activity	Unacceptable Absent or incomplete	Acceptable All components adequately addressed	Good All components thoroughly, expertly addressed
2. Mood and Affect	Unacceptable Absent or incomplete	Acceptable All relevant aspects adequately addressed	Good All relevant aspects adequately addressed; use of standardized rating scales
3. Thought disorder thought form, thought content	Unacceptable Absent or incomplete	Acceptable All relevant aspects adequately addressed	Good All relevant aspects adequately addressed; use of standardized rating scales
4. Perceptual hallucination, depersonalization	Unacceptable Absent or incomplete	Acceptable All components adequately addressed	Good All components thoroughly, expertly addressed
5. Cognition	Unacceptable Absent	Acceptable Qualitative remarks on cognitive performance	Good Standardized test(s); neurological tests of frontal lobe function
Safety Assessment
	Unacceptable Red 0 pts	Acceptable Green 3 pts	N/A (N/A)
6. Self Harm	Unacceptable Absent or incomplete	Acceptable All relevant aspects adequately addressed	N/A
7. Harm to others	Unacceptable Absent or incomplete	Acceptable All relevant aspects adequately addressed	N/A