iRubric: Rubric for Basic Charting Information

(draft) edit print share Copy to my rubrics Bookmark test run assess... delete Do more...

Rubric for Basic Charting Information

Rubric which is used to grade charting entries for CNA students.

Rubric Code: D47WX8

By eewalker

Draft

Public Rubric

Subject: Vocational

Type: Assignment

Grade Levels: 9-12

Legibility Entries on chart are handwritten or legibly printed.
	Poor 1 pts	Fair 2 pts	Good 3 pts
Error correction 10 pts There are no ditto marks, white out, erasures, and blacking out with marker for error corrections	Poor Entries are frequently illegible. Entries usually not neat or are difficult to decipher.	Fair Some entries are illegible. Entries are sometimes difficult to decipher and not neat.	Good Entries are always legible and neat. No difficulty deciphering entry.
Timely Recording 10 pts All entries were recorded after completion of tasks	Poor Many entries were recorded long after tasks were completed. Not always signed with correct information.	Fair Most of the entries were recorded directly after tasks were completed. Most of the time they were signed correctly	Good All of the entries were recorded directly after tasks were completed. Correct signatures were in plase after entries.
Exactness 10 pts Exact time, effect and results of all treatments and procedutes noted correctly	Poor Many entries did not note time, effect, or result of all treatments and procedures. Descriptions of type, location, onset, duration , and severity of pain not correctly noted.	Fair Most of entries had correct time, effect, or result of all treatments and procedures. Most of the descriptions of the type, location, onset, duration and severity of pain correctly noted.	Good All or entries had correct time, effect, or result of all treatments and procedures. The descriptions of the type, location, onset, duration and severity of pain were correctly noted.
Noting time 10 pts Note the time of physician's visit, examination, and treatments.	Poor Physician's visit, examination or treatments not correctly charted.	Fair Physician's visits, examinations, or treatments recorded correctly most of the time.	Good Physician's visits, examinations, or treatments always recorded correctly.
Blank areas 10 pts No blank lines in the charting.	Poor Frequent blank lines in charting.	Fair Occasional blank line in charting	Good No blank lines in charting.
Ink 5 pts Use color ink according to your facility's policy	Poor Used many colors of ink in charting.	Fair Occasionally used an unacceptable color of ink in charting.	Good Always used blue or black ink in charting.
Military Time 10 pts Military time used when charting.	Poor Sometimes used military charting.	Fair Occasionally did not use military charting.	Good Always used military time in charting.
Medical Abbreviation 10 pts Use standard medical abbreviations	Poor Frequently used incorrect medical abbreviations when charting.	Fair Occasionally used incorrect medical abbreviations when charting.	Good Always used correct medical abbreviations when charting.
Proper heading 5 pts Proper heading must be written, stamped or printed according to facility policy.	Poor Frequently the heading on the pages of the charting were missing	Fair Occasionally the heading on the pages of the chart were missing	Good Heading on pages of chart were always either written in, stamped, or typed on chart pages.
Tense 5 pts Use present or past tense	Poor Frequently did not use proper tense when charting.	Fair Occasionally did not use proper tense when charting.	Good Always used past or present tense in charting.
Correct spelling 5 pts Spell correctly.	Poor Frequently there were misspelled terms in charting.	Fair Occasionally there were misspelled terms in charting.	Good Never used misspelled terms when charting.
Mistakes in charting 5 pts When charting and mistakes are made, no ditto marks, white out, erasures, and blacking out acceptable.	Poor Ditto marks, white out, erasures, and blacking out often seen in charting	Fair Ditto marks, white out, erasures, and blacking out occasionally seen in charting	Good Ditto marks, white out, erasures, and blacking out not noted in charting.

Keywords:

charting, recording, ditto, erasures

Subjects:

Vocational

Types:

Assignment

Discuss this rubric