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iRubric: Nursing 102 Clinical rubric

iRubric: Nursing 102 Clinical rubric

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Nursing 102 Clinical 
Nursing 102 Clinical
Clinical Paperwork and EHR
Rubric Code: WXW5C7C
By beana928
Ready to use
Public Rubric
Subject: Nursing  
Type: Writing  
Grade Levels: Undergraduate

Powered by iRubric Clinnical Paperwork and EHR
  Below Average

1 pts

Average

2 pts

Above Average

3 pts

Exceptional

4 pts

Comments/Points

(N/A)

Preclinical Data & Development

Summarize events leading up to admission, why brought to this facility. Need subjective data "according to patient", objective data, "according to chart, family, etc. Documentation is clear and well organized
Below Average

Documentation does not meet expectations for this level as evidenced by any of the following:
No data from pt, No data from medical record and/or staff member, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism noted from other health care provider notes.
Average

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence for data fro admission summary from patient, medical record and/or staff & family memeber for admission to facility. The reader is able to determine findings with difficulty.
Above Average

Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for admission summary documentation from patient, medical record and/or staff memebrs/family. The reader is able to determine findings with minimal difficulty.
Exceptional

Documentation is clear and well organized.
Appropriate medical terminology is used.
Redundant (repetitious) words, phrases, and other distracting information are omitted.
Format follows a standard for admission summary documentation from patient, medical record and/or staff memebrs/family. The reader is able to determine findings without difficultynd has a logical flow.
Comments/Points
Current Treatment

Include times, frequency and important supportive data.
Below Average

Assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's situation. Irrelevant information predominates subjective & objective assessment
Average

Asessment is missing 2 elements needed for adequate evaluation of the patient's situation. Includes irrelevant information subjective and objective.
Above Average

Assessment is missing 1 element needed for adequate evaluation of the patient's situation for subjective and objective data. Gives 1-2 examples
Exceptional

Assessment of Social & cultural status is fully explicated
and targeted toward the reason for presentation without the inclusion of extraneous information.
assessment is fully developed subjectively and objectively. Examples given to support data, note specific and detailed
Comments/Points
Pertinent Lab, X-ray, test, etc.

Pertinent lab/ x-ray, diagnostic procedure results within the last 30 days. Must include CBC, metabolic profile and medication specific tests even if past 30 days, use latest. List normal ranges and highlight abnormals with the reason you suspect they are abnormal r/t pt. DX.
Below Average

Documentation does not meet expectations for this level as evidenced by any of the following: no CBC and/or metabolic profile, specifc diagnostic test, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism noted from other health care provider notes.
Average

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical Pertinent lab/ x-ray, diagnostic procedure results within the last 30 days. CBC and/or metabolic profile and medication specific tests do not list normal ranges nor highlight abnormals with the reason you suspect they are abnormal r/t pt. DX.
Above Average

Documentation meets criteria for clarity, "exceptional" but there is occasional redundant or distracting information & needs to be better organized.
Occasionally strays from standard format for logical Pertinent lab/ x-ray, diagnostic procedure results within the last 30 days. CBC and metabolic profile and medication specific tests listed with normal ranges and highlight abnormals. Rationale for why you suspect they are abnormal r/t pt. DX. attempted and some missing.
Exceptional

Documentation is clear and well organized.
Appropriate medical terminology is used.
Redundant (repetitious) words, phrases, and other distracting information not seen. Meets criteria for clarity, well organized, format for logical Pertinent lab/ x-ray, diagnostic procedure results within the last 30 days. CBC and metabolic profile and medication specific tests listed with normal ranges and highlight abnormals. Rationale for why you suspect they are abnormal r/t pt. DX. correct and all li
Comments/Points
Significant assessment findings

Relate to head to toe assessment, diagnosis and treatments
Below Average

Documentation does not meet expectations for this level as evidenced by either of the following: does not clearly show significant findings, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism noted from other health care provider notes.
Average

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical thinking but the reader is able to determine findings with difficulty.
Above Average

Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for significant assessment findings but the reader is able to determine findings with minimal difficulty.
Exceptional

Documentation is clear and well organized.
Appropriate medical terminology is used.
Redundant (repetitious) words, phrases, and other distracting information are omitted. Significant assessment findings follows a standard and has a logical flow.
Comments/Points
Medication

Follows Medication card format and includes all required data such as classification, brand/generic name, actions, side effects, nursing considerations, etc. Is prepared for medication adminstration and can discuss key apsects of assigned meds
Below Average

Not done and turned in
Average

Medication brand/generic names and or classification missing, Minimal action effects are described or none, missing side effects, and important teaching components.
Above Average

Uses either some generic or some of the brand names, Identifies some of the therapeutic or pharmacological classifications of medication, Partially describes action effects including therapeutic effect of medication. Missing dose or normal dose range information, Some of the system side effects are described, Some of the patient/family teaching areas are identified
Exceptional

Uses all Generic and Brand name, Identifies all the therapeutic and pharmacological classifications Completely describes the action effects including therapeutic effect of medication. Dose identified with normal range, all systems described. Drug-drug and drug-food interactions, All patient/family teaching areas are identified.
Comments/Points






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