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iRubric: EMS Chart review rubric

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EMS Chart review EMS Chart review Patient care report QI review Rubric Code: LXW6X88 By ahasti Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: 9-12

Patient Care Report
	Unacceptable 0 pts	Poor 1 pts	Fair 2 pts	Good 3 pts	Excellent 4 pts
Legibility	Unacceptable Unable to read	Poor Difficult to read	Fair Hand-written with errors	Good Typed with errors or hand-written and easy to read	Excellent Typed and easy to read
Completeness	Unacceptable Critical information is missing	Poor Important information is missing	Fair Some information is missing	Good Information is complete	Excellent Information is complete and well organized.
Complaint	Unacceptable None documented	Poor Documented poorly	Fair Documented without explaination	Good Documented and explained	Excellent Documented and well- described with onset, time, and adequate descriptors
History	Unacceptable None documented	Poor Documented poorly	Fair Documented, but missing information	Good Documented and explained	Excellent Documented and well described with PMH, meds, allergies
Assessment	Unacceptable None documented	Poor Documented poorly, leaving out key pertinent positives and negatives	Fair Documented, but missing some pertinent information.	Good Documented with all pertinent information.	Excellent Documented with indications of extensive assessment including differential assessment. Also documents reassessment.
Treatment	Unacceptable None documented	Poor Documentation indicates poor treatment modalities or treatment is documented poorly.	Fair Documented but not followed by effects of treatment.	Good Appropriately documented treatment.	Excellent Documented well, indicating appropriate treatment and describes effects of treatment.
Transport	Unacceptable None documented	Poor Documented inappropriate transport decision.	Fair Transport decision not appropriately documented.	Good Appropriate transport decision documented.	Excellent Appropriate transport decision documented with justification.