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iRubric: History and Physical Assessment rubric

iRubric: History and Physical Assessment rubric

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History and Physical Assessment 
History and Physical Assessment
History and Physical of patient in Western Clinical Medicine
Rubric Code: HX89C82
By clinicalskills
Ready to use
Public Rubric
Subject: Medical  
Type: Exam  
Grade Levels: Graduate

Powered by iRubric Health and Physical Assessment
  Failing

0 pts

Fair

70 pts

Good

90 pts

Very Good

100 pts

Essential Tasks
10 %

1. Introduces self
2. Identifies patient
3. Washes Hands
4. Determines existence of allergies, medications, herbal preps, etc
Failing

Students fails to perform 2 or more required tasks
Fair
Good
Very Good

Student performs all required tasks
General Physical Assessment
30 %

1. Obtains the Chief Complaine
2. Asks the appropriate questions related to the the CC and expands the HPI
3. Gathers pertinent past medical history, ROS, Family, Psychosocial
4. Performs Physical Exam
Using the appropriate techniques of
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
Failing

Inadequate history taking, fails to gather pertinent positive negatives, ROS, or important PMHx, Social, etc.
Inadequate assessment performed
Fair

Student performs marginally effective assessment
Good

Student performs efficient assessment of assigned body system with minor omissions in technique, teaching, or performance.
Very Good

Student performs efficient assessment of assigned body system covering all gradable points with no omissions and is able to answer all questions posed by instructor or patient. Student also provides effective patient teaching during designated time limit.
Reporting
30 %

Report should have following components:
SUBJECTIVE
1. Biographical Sketch
2. Chief complaint or reason for visit
3. Patient Hx using initals and no identifying number
4. Previous illnesses and/or surgeries
5. Narrative Review of System
OBJECTIVE
1. Results of physical exam.
2. Any followup action plan or tests
Failing

Students narrative and or written is inadequate with gross deficiencies
Fair

Student fails to address all elements in detail during presentation or has significant grammatical and spelling errors in case repot
Good

Student addresses all key elements in narrative with minor grammatical errors, spelling, or fomatting errors.
Very Good

Student effectively correctly addresses every key element of the assessment in a narrative having the proper format with no grammatical or spelling errors.
Communication
30 %

Effective professional communication orally and in writing.
Failing

Failure to communicate .
Fair

Student does not explain assessment to patient or talks minimally to patient
Good

Student explains the assessment as they are completing each step.
Very Good

Student explains the assessment as they are completing each step and is able to answer with confidence all patient questions in a calm and efficient manner.






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