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iRubric: History and Physical Assessment rubric

iRubric: History and Physical Assessment rubric

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History and Physical Assessment 
History and Physical Assessment
History and Physical of patient in Western Clinical Medicine
Rubric Code: EXB4869
By crobison
Ready to use
Public Rubric
Subject: Medical  
Type: Exam  
Grade Levels: 9-12, Graduate

Powered by iRubric Clinical Performance Rubric
  Not Competent

0 pts

Minimally Competent

70 pts

Competent

90 pts

Fully Competent

100 pts

Essential Tasks
10 %

1. Introduces self<BR>
2. Identifies patient<BR>
3. Washes Hands <BR>
4. Determines existence of allergies, medications, herbal preps, etc
Not Competent

Students fails to perform 2 or more required tasks
Minimally Competent
Competent
Fully Competent

Student performs all required tasks
General Physical Assessment
20 %

1. Obtains the Chief Complaint<BR>
2. Asks the appropriate questions related to the the CC and expands the HPI <BR>
3. Gathers pertinent past medical history, ROS, Family, Psychosocial<BR>
4. Performs Physical Exam <BR>
Using the appropriate techniques of <BR>
a. Inspection<BR>
b. Palpation<BR>
c. Percussion<BR>
d. Auscultation
Not Competent

Inadequate history taking, fails to gather pertinent positive negatives, ROS, or important PMHx, Social, etc.<BR>
Inadequate assessment performed
Minimally Competent

Student performs marginally effective assessment
Competent

Student performs efficient assessment of assigned body system with minor omissions in technique, teaching, or performance.
Fully Competent

Student performs efficient assessment of assigned body system covering all gradable points with no omissions and is able to answer all questions posed by instructor or patient. Student also provides effective patient teaching during designated time limit.
Documentation
25 %

Report should have following components: <BR>
SUBJECTIVE<BR>
1. Biographical Sketch <BR>
2. Chief complaint or reason for visit <BR>
3. Patient Hx using initals and no identifying number <BR>
4. Previous illnesses and/or surgeries <BR>
5. Narrative Review of System<BR>
OBJECTIVE<BR>
1. Results of physical exam. <BR>
2. Any followup action plan or tests
Not Competent

Students narrative and or written is inadequate with gross deficiencies
Minimally Competent

Student fails to address all elements in detail during presentation or has significant grammatical and spelling errors in case repot
Competent

Student addresses all key elements in narrative with minor grammatical errors, spelling, or fomatting errors.
Fully Competent

Student effectively correctly addresses every key element of the assessment in a narrative having the proper format with no grammatical or spelling errors.
Communication
25 %

Effective professional communication orally and in writing.
Not Competent

Failure to communicate .
Minimally Competent

Student does not explain assessment to patient or talks minimally to patient
Competent

Student explains the assessment as they are completing each step.
Fully Competent

Student explains the assessment as they are completing each step and is able to answer with confidence all patient questions in a calm and efficient manner.
Demonstrated Clinical Performance
20 %

Demonstrated correct technique(s) with Use of Equipment
Not Competent

Failure to properly use correct technique with use of equipment < than 50% of the time
Minimally Competent

Demonstrates correct technique and proper use of equipment the more than 50% of the time but not consistently
Competent

Consistently demonstrates correct technique and proper use of equipment the more than 80% of the time
Fully Competent

Consistently demonstrates correct technique and proper use of equipment






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