iRubric: Written H&P - Summative Evaluation rubric

Documents the patient's primary reason for presenting to the office in the patient's own words and includes symptoms duration.

Documents the primary reason but it is not in the patients words and/or does not include duration of symptoms.

Not documented.

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.

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.

Incomplete or missing components of the history.
Medications and/or allergies are incomplete.

Documents a complete and thorough social history including: Education and Employment History, Sexual History, Personal Status/Religion and, Habits.
Includes details about each topic.

Documents all sections of the social history but details are limited and do not provide a complete picture of who the patient is.

Not documented or is missing several sections of the social history.

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.

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.

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.

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.

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.

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.