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iRubric: Collecting Patient History rubric

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Collecting Patient History Medical Assisting Assessment How to collect all necessary data in the clinical setting in order to write a complete Patient Assessment. Rubric Code: A22523X By jcampbell1 Ready to use Public Rubric Subject: Medical Type: Project Grade Levels: Undergraduate

Assessment Skill
	Good 4 pts	Fair 3 pts	Poor 2 pts	1 pts
Greeting patient	Good Introduces himself/herself. Greets patient and verifies patient identity.	Fair Introduces himself/herself. Greets patient but does not verify patient identify	Poor Does not introduce himself/herself. Greets patient and verifies patient identity.	1 Does not introduce himself/herself. Does not greet patient nor verify patient identity.
Vital Signs	Good Explains procedure. Obtains blood pressure, pulse, respirations, and temperature correctly.	Fair Explains procedure. Only obtains three of four vital signs correctly.	Poor Explains procedure. Only obtains two of four vital signs correctly.	1 Does not explain procedure. Only obtains one of four vital signs correctly.
Present Illness Assessment	Good Obtains detailed illness history, including date/time of onset, provocation of illness/injury (what caused it), detailed description of signs/symptoms/pain, rating of pain on the 0-10 scale, quality of pain (sharp, stabbing, etc.), radiation of pain (does it travel and if so where), and relief measures/medication tried and their effectiveness.	Fair Obtains illness assessment but misses one of the critical areas described.	Poor Obtains illness assessment but misses two of the critical areas described.	1 Obtains illness assessment but misses three or more of the critical areas described.
Necessary Testing	Good Obtains any specimen necessary and performs in office testing.	Fair Obtains any specimen necessary but performs only part of the necessary testing.	Poor Obtains any specimen necessary but does not perform correct testing.	1 Does not obtain nor test any specimen.