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iRubric: Written H&P - CPRE rubric
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Written H&P - CPRE
Written H&P - Summative Evaluation
Rubric Code:
B2X5CB7
By
mzarko
Ready to use
Public Rubric
Subject:
Medical
Type:
Assessment
Grade Levels:
(none)
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Written History and Physical Examination
Complete/Proficient
3 pts
Parital/Adequate
1 pts
Absent/Inadequate
0 pts
Identifying Data
Complete/Proficient
Includes patients, name, date of birth, source of information, reliability of source and referral source (if patient was referred).
Parital/Adequate
Incomplete information.
Absent/Inadequate
Not documented.
Chief Complaint
Complete/Proficient
Documents the patient's primary reason for presenting to the office in the patient's own words and includes symptoms duration.
Parital/Adequate
Documents the primary reason but it is not in the patients words and/or does not include duration of symptoms.
Absent/Inadequate
Not documented.
History of Present Illness
Complete/Proficient
Documents a clear, organized, chronological description of the presenting problem including a detailed description of the symptoms (OLDCARTS).
Documents the presence and/or absence relevant of medical illness/conditions, family history and social history.
Documents relevant positive and negative review of systems.
Parital/Adequate
Documents a description of the presenting problem (OLDCARTS) but it is not clear or organized.
Documentation of relevant medical history, family history, social history and review of systems is present but not complete.
Absent/Inadequate
Document is unorganized and does not provide a clear picture of the presenting symptom. Relevant history and/or review of systems is minimal and/or missing key data.
Past Medical History
Complete/Proficient
Documents a thorough past medical history including: Adult/Childhood Illnesses, Surgical History, Hospitalizations, Major Injuries, Medications/Supplements, Allergies, Immunizations and, Health Maintenance/Recent Screening Tests.
Documentation is complete and includes descriptive details for each (ep. date, indication, outcomes, etc)
Medication list does includes all required information (dose, frequency, route)
Allergies include reaction type.
Parital/Adequate
Documents all components of the past medical history but information is incomplete - Dates, indications, outcomes are not present.
Medication list does not includes all required information (dose, frequency, route)
Allergies do not include reaction type.
Absent/Inadequate
Incomplete or missing components of the history.
Medications and/or allergies are incomplete.
Family History
Complete/Proficient
Documents or diagrams the medical history of each immediate family member.
Includes the age and health or age and cause of death for each immediate family member.
Parital/Adequate
Documents or diagrams the medical history of each immediate family member.
Includes some but not all of the required information about age and health or age and cause of death for each immediate family member.
Absent/Inadequate
Does not document or documents only the medial history of each family member. Does not include information about current age/health or age/cause of death.
Social History
Complete/Proficient
Documents a complete and thorough social history including: Education and Employment History, Sexual History, Personal Status/Religion and, Habits.
Includes details about each topic.
Parital/Adequate
Documents all sections of the social history but details are limited and do not provide a complete picture of who the patient is.
Absent/Inadequate
Not documented or is missing several sections of the social history.
Review of Systems
Complete/Proficient
Documents a complete and thorough review of systems for all 14 systems.
Includes at least 3 relevant positive and/or negative symptoms for each system reviewed.
The documented ROS includes information that helps narrow the differential diagnosis.
Parital/Adequate
Documents a complete and thorough review of systems for all 2-10 systems.
Includes at least 3 relevant positive and/or negative symptoms for each system reviewed.
The documented ROS is missing some information that helps narrow the differential diagnosis but it is overall still helpful.
Absent/Inadequate
Does not document a review of systems or documentation includes less than 3 symptoms per system reviewed.
The documented ROS does not includes enough relevant information that help narrow the differential diagnosis.
Physical Examination
Complete/Proficient
Documents a complete and thorough head-to-toe examination, including the presence and/or absence of pertinent exam findings needed to evaluate the presenting problem. The documented examination helps narrow the differential diagnosis.
Parital/Adequate
Documents a complete and thorough head-to-toe examination, but it is missing details about the presence and/or absence of pertinent exam findings needed to evaluate the presenting problem. The documented examination is still sufficient to narrow the differential diagnosis.
Absent/Inadequate
Documentation is missing systems and/or it is missing details about the presence and/or absence of pertinent exam findings that are crucial to evaluating the presenting problem. The documented examination does not help narrow the differential diagnosis.
Diagnostic Studies: Labs, Imaging, etc.
Complete/Proficient
Documents diagnostic studies relevant to the presenting problem.
Includes results.
Studies and results clearly narrow the differential diagnosis.
Parital/Adequate
Documents diagnostic studies but they are not all relevant to the presenting problem and/or studies are missing.
Results are incomplete but the information is sufficient to narrow the differential diagnosis.
Absent/Inadequate
Missing several studies and/or data is missing which is needed to narrow the differential diagnosis.
Assessment
Complete/Proficient
Summarizes the patient and chief complaint. Documents a Problem List including a diagnosis or list of differential diagnoses for each problem. Supports the diagnosis/differential diagnosis with subjective and/or objective data.
Overall, The assessment demonstrates that the learner can organize the subjective and objective information given and formulate a diagnosis or differential diagnosis. The learner's impression of the patient's symptoms is clear to the reader.
Parital/Adequate
All components are present. Overall, the assessment demonstrates that the learner has obtained the information to arrive at a diagnosis or differential diagnosis but the rational is not clear. The learner's impression of the patient's symptoms in not clear to the reader.
Absent/Inadequate
Missing components
-or-
The assessment does not demonstrates that the learner has obtained the necessary information to arrive at a diagnosis or differential diagnosis. It is not organized and the learner's impression of the patient's symptoms in not clear to the reader.
Plan
Complete/Proficient
Documents a well organized plan for each problem on the problem list.
The plan demonstrates clinical reasoning and includes appropriate diagnostic studies, treatments plan, patient education and, follow up.
Parital/Adequate
Documents a well organized plan for each problem on the problem list.
The plan includes includes a combination of: diagnostic studies, treatments plan, patient education and, follow up.
Components of the plan are incomplete or irrelevant.
Absent/Inadequate
The plan is incomplete or poorly organized. The workup, treatment and/or follow up is unclear.
Subjects:
Medical
Types:
Assessment
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