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iRubric: Case Presentation rubric

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Case Presentation 
Case Presentation
Rubric Code: F224275
By runez1
Ready to use
Public Rubric
Subject: (General)  
Type: Assignment  
Grade Levels: Graduate

Powered by iRubric Nursing Clinical Case Study
100 %
  Fair

(N/A)

Good

(N/A)

Excellent

(N/A)

Comments

(N/A)

HISTORY OF PRESENT PROBLEM
10 %

S) Chief complaint,(always stated in patient's/client’s own words). History of present illness.
Fair

History is scant. The majority of vital information is missing relating to the chief complain
Good

Well presented; 1-2 areas of pertinent information not presented.
Excellent

Presentation is excellent; all pertinent information presented.
Comments
PATIENT PAST MEDICAL HISTORY
10 %

Complete subjective health history.
General medical history/health Status
Fair

Past medical History is scant. The majority of vital information is missing relating to the chief complaint.
Good

History is age/gender appropriate and contains pertinent information. However, it is missing some vital points relating to the chief complaint.
Excellent

History is complete and age/gender appropriate. It is presented in logical format.
Comments
PATIENT PERSONAL/ SOCIAL HISTORY
10 %

Family history
Social history
Mental status
Substance use
Fair

Social history is fairly presented; 1-2 areas of pertinent information not presented.
Good

Social History is well presented; some patient data missing or unclear; pertinent information presented.
Excellent

Well presented; all pertinent information presented.
Comments
PATIENT ASSESSMENT
20 %

(O) Objective data including a physical and mental assessment, labs, diagnostic procedures, etc.
Fair

The assessment lists the chief complaint/main problem for the patient but 2-3 problems are not presented. No laboratory work of diagnostic tests presented. Provides a few random objective findings.
Good

The assessment lists the chief complaint/main problem for the patient but one or more problems is missing. Appropriate laboratory work and diagnostics tests - there are one or more missing.
Excellent

The assessment lists ALL of the pertinent problems for the patient, not just the chief complaint. All appropriate labs and diagnostic tests are recorded.
Comments
DIAGNOSIS
20 %

(A) a comprehensive
assessment/differential diagnosis list and actual diagnosis
Fair

Lists the diagnosis rather than a set of differential diagnoses
Good

Provides a general list of diagnoses that are not specific to the information provided in the patient and findings sections
Excellent

Provides a concise set of potential diagnoses that are relevant to the
information provided in the patient and findings sections. Provides a final diagnosis along
Comments
TREATMENT
20 %

(P) Summary of the plan including pharmacological and non-pharmacological treatments.
Fair

The summary of treatment is fair and 75% facts are omitted. A generic, non-detailed summary of treatments provided.
Good

The summary of treatment is adequate with 50% facts omitted. A minimum amount of information specific to interventions.
Excellent

There is a complete discussion of the actual treatment including rationale for treatment.
Comments
PATIENT EDUCATION
10 %

Appropriate health teaching, and health prevention/ promotion/screening.
Fair

The summary of education, health prevention and health promotion is fair and 75% facts are omitted -based on clinical guidelines or evidence based practice.
Good

The summary of education, health prevention and health promotion is adequate and 50% facts are omitted - based on clinical guidelines or evidence based practice.
Excellent

The summary of education, health prevention and health promotion s adequate and appropriate - based on clinical guidelines or evidenced based practice.
Comments





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