iRubric: H&P Practical - Head and Neck rubric

Inspected, verbalized bilateral assessment of:
1. Eyebrows
2. Eyelashes
3. Upper /Lower lids
4. Lacrimal apparatus
5. Conjunctiva
6. Sclera
7. Corneas
8. Pupils<BR>
9. Iris
10. Eye alignment - checked light reflex in both corneas

Inspected, verbalized assessment of 5-9 areas

Inspected, verbalized assessment of 1-5 areas

Did not verbalize inspection of the eyes

Tested both direct and consensual pupillary reaction to light. Paused between each test for pupil to return to normal size.

Did not pause an adequate amount of time for pupil to return to normal size

Tested only direct or consensual pupillary reaction to light; not both

Did not assess pupillary reaction to light

1. Explained procedure to the patient<BR>
2. Dimmed the lights<BR>
3. Held Opthalmoscope in correct hand and used the correct eye for examination<BR>
4. Used a mechanism to avoid getting too close to the patient or losing balance
5. Was close enough to patient to adequately examine the fundus
6. Verbalized assessment of the vessels, optic disc, retina

Omitted or incorrectly performed 1-2 elements of the fundoscopic exam

Omitted or incorrectly performed 3-4 elements of the fundoscopic exam

Omitted or incorrectly performed >4 elements of the fundoscopic exam

1. Gently pulled on auricle to straighten ear canal
2. Used a safety mechanism to avoid trauma to TM or ear canal (bracing finger)
3. Inspected and verbalized assessment of ear canal and tympanic membrane

Did not verbalize assessment of ear canal and TM or did not properly pull on the auricle

Did not use a safety mechanism when examining the ear canal and TM

Did not do an otoscopic exam, or did not perform any of the required steps

1. Inspected inside of nares with the otoscope, avoiding contact with the nasal septum
2. Verbalized assessment of nasal mucosa and nasal septum

Did not verbalize assessment of nasal mucosa OR nasal septum

Did not avoid contact with the nasal septum OR did not verbalize assessment

Did not perform the nares examination OR did not avoid contact with septum AND did not verbalize assessment

Inspected and verbalized assessment of:
1. Lips
2. Oral Mucosa
3. Gums and Teeth
4. Roof of Mouth
5. Tongue/Floor
6. Pharynx, using light and tongue blade to assess all areas

Thoroughly inspected and verbalized assessment of 4-6 areas of the mouth

Thoroughly inspected and verbalized assessment of 1-3 areas of the mouth OR verbalized all areas, but did not assess thoroughly OR did not use a light and/or tongue blade

Did not examine the mouth, OR did not thoroughly inspect or verbalize any areas

Palpated the trachea for position and the thyroid gland
1. Neck slightly forward
2. Fingers of both hands on pts. neck with index fingers just below the cricoid cartilage
3. Asked pt. to sip water, 4. Displaced trachea to one side, examining opposite lobe of gland, repeated on opposite side

Palpated the trachea for position and the thyroid gland, correctly performing 3 of the steps of the thyroid examination

Palpated for tracheal position and the thyroid gland, correctly performing 1-2 of the steps of the thyroid examination OR correctly performed 3-4 of the steps of the thyroid examination AND did not palpate for tracheal position

Did not palpate for trachea position or the thyroid gland or performed incorrectly