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iRubric: Documentation Metadata rubric

iRubric: Documentation Metadata rubric

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Documentation Metadata built by lmyronuk

Rubric Code: XX9XW67
For use in quality review of psychiatric records.
ready Ready to use    public Public Rubric

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Keywords: file, chart, quality, review, psychiatry
Categories: Subjects: Medical  
Types: (Other)  
Grade Levels: Graduate, Post Graduate

Powered by iRubric Documentation Metadata
Process measures unrelated to document content.
  Unacceptable
0 pts Red
Needs improvement
1 pts Yellow
Good
3 pts Green
Timeliness
Was the documentation completed at the time of service?
Unacceptable

Greater than two weeks from time of service, or not completed.
Needs improvement

Greater than 48h from time of service but within two weeks.
Good

Within 48h from time of service.
Distribution
Were appropriate service providers copied in?
Unacceptable

Most-responsible or primary care provider (MRP, PCP) not copied; wrong PCP identified; no cc recipients specified.
Needs improvement

Most-responsible or primary care provider (MRP, PCP) copied, but other service providers (specialists, care facility, etc.) not copied.
Good

All appropriate care providers included in copy distribution.
Proofreading
Was the documentation posted and distributed with uncorrected errors.
Unacceptable

Document posted to chart and distributed according to HIM policy without having been proofread, corrected, and signed by author.
Needs improvement

Document signed by author and distributed containing uncorrected errors.
Good

Document signed with review and correction of errors (could be in form of addendum to document).
Filing
Is the document residing in the correct location within the patient's health record?
Unacceptable

Document is in the wrong section of paper chart or incorrect document type in EHR.
Needs improvement

Correct document location, but document not titled or titled inappropriately (e.g., "Free text note")
Good

Document in correct location within patient record with suitable descriptive title.



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