iRubric: Narrative Nursing Notes Rubric

Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment

Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.

Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.

Subjective assessment of health status is fully explicated
and targeted toward the reason for presentation without the inclusion of extraneous information.
assessment is fully developed and includes location, duration, timing, character, severity provocative/palliative factors and/or other features appropriate for the reason for presentation.
Note specific and detailed

Documentation does not meet expectations for this level as evidenced by either of the following: does not clearly state pt is alive at time of "first look", safety precautions in place, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism noted from other health care provider notes.

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence for "first look" note and safety but the reader is able to determine findings with difficulty.

Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for "first look" and safety documentation but the reader is able to determine findings with minimal difficulty.

Documentation is clear and well organized.
Appropriate medical terminology is used.
Redundant (repetitious) words, phrases, and other distracting information are omitted. "first look" and safety format follows a standard and has a logical flow.

Incorrectly or fails to apply evidence-based guidelines to assesment, DX, plan, patient education, or follow-up. Does not meet expectations for this level as evidenced by either of the following: does not clearly show follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. Use of lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism from other health care provider noted

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. The reader is able to determine findings with difficulty.

Includes 2 or more errors in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up

Documentation meets criteria for "exceptional" but there is occasional redundant/distracting info. Follow up plan is appropriate and meets above criteria but is "generic" occasionally strays from standard format for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. Includes only 1 minor error in the application or omission of evidence-based guidelines to assessment,DX,plan, patient education, or follow-up

Documentation is clear &well organized.
Appropriate medical terminology & pharses. Redundant words & other distracting info. are omitted. Follow up to pain, prn meds, urgent situations, or abnormalities in head to toe assessment follow a standard & has logical flow.
Plan is appropriate for the DX & accurately addresses the problem identified
for evaluation/follow-up care using evidence-based guidelines without omission to assessment, DX, plan, Pt. education, pt. needs, culture, relig