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iRubric: Health History and Physical Assessment rubric

iRubric: Health History and Physical Assessment rubric

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Health History and Physical Assessment 
Health History and Physical Assessment
Rubric for writing up a Comprehensive Health Assessment
Rubric Code: D2345CA
By deeberto
Ready to use
Public Rubric
Subject: Nursing  
Type: Assignment  
Grade Levels: Undergraduate, Graduate

Powered by iRubric Comprehensive Health Assessment
  Inadequate effort

0 pts

Fair

1 pts

Good

2 pts

Very Good

3 pts

Score

(N/A)

Part I-Biographical Data
3 pts

Includes all pertinent objective data
Inadequate effort

Student provides no biographical information.
Fair

Student provides less than 5 items of biographical data.
Good

Student provides 5 to to 7 items of biographical data.
Very Good

Student includes all elements of biographical data.
Score
Part 1-Continued
  Inadequate Effort

0 pts

Fair

2 pts

Good

4 pts

Very Good

6 pts

Score

(N/A)

Reason for Seeking Care
6 pts

Provides clearly written explanation for patient appointment
Inadequate Effort

Fails to provide a focused written statement for reason/feelings about seeking care.
Fair

Provides a vaguely written statement for reason/feelings about seeking care.
Good

Provides a clearly written statement for reason/feelings for and about seeking care.
Very Good

Provides a focused clearly written statement regarding the patient reason/feelings for and about seeking care. Places reason in quotations.
Score
History of Present Health Concern
6 pts

Includes comprehensive subjective data
Inadequate Effort

Documentation is inadequate with gross deficiencies in grammar, spelling and/or formatting(word usage).
Fair

Documentation fails to address all elements in detail or has significant grammatical,spelling, and /or word usageerrors.
Good

Documentation addresses all elements with minor grammatical, spelling, or word usage errors.
Very Good

Documentation correctly addresses every element of the assessment having the proper format with no grammatical, spelling, or word usage errors.
Score
Medical/Family Health History
6 pts

Includes comprehensive health history data
Inadequate Effort

Documentation is inadequate with gross deficiencies in grammer, spelling, and/or word usage.
Fair

Documentation fails to address all elements in details or has significant grammatical, spelling, and or word usageerrors.
Good

Documentation addresses all key elements with minor grammatical errors, spelling, or word usage errors.
Very Good

Documentation correctly addresses every key element of the assessment having the proper format with no grammatical, spelling or word usage errors.
Score
Lifestyle
6 pts

Includes comphrehensive lifestyle data
Inadequate Effort

Documentation is inadequate with gross deficiencies in grammer, spelling, and or word usage.
Fair

Documentation fails to address all elements in details or has significant grammatical, spelling, and /or word usage errors.
Good

Documentation addresses all key elements with minor grammatical errors, spelling, and/or word usage errors.
Very Good

Documentation correctly addresses every key element having the proper format with no grammatical, spelling or word usage errors.
Score
Part II-Prevention and Maintenance
  Inadequate

0 pts

Fair

2 pts

Good

4 pts

Very Good

6 pts

Score

(N/A)

Part II-Prevention and Maintenance
6 pts

Lists learning needs based on health history and identified needs. Prioritizes list.
Inadequate

Student provides no recommendations.
Fair

Student provides one recommendation.
Good

Student provides at least 2 prioritized recommendations.
Very Good

Student provides at least 3 prioritized recommendations.
Score
Part III-Physical Assessment(ROS)
  Inadequate

0 pts

Fair

6 pts

Good

12 pts

Very Good

17 pts

Score

(N/A)

Part III-Physical Assesment(ROS)
17 pts

Assess all systems appropriately using inspection, palpation and auscultation as indicated. Appropriately assess all negative findings.
Document all findings concisely using appropriate terminology.
Inadequate

Student provides no physical examination documentation.
Fair

Student provides minimal physical examination documentation with numerous grammatical, spelling or word usage errors.
No evidence of further assessment of negative findings.
Good

Student provides adequate physical examination documentation that covers majority of systems with minimal grammatical, spelling or word usage errors.
Evidence of appropriate assesment of negative findings documented.
Very Good

Student provides adequate physical examination documentation that covers all systems using inspection, palpation, auscultation as appropriate with no grammatical, spelling or word usage errors.
Evidence of appropriate assessment of negative findings documented.
Score






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