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iRubric: Student nurse narrative nursing note rubric
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Student nurse narrative nursing note
Student nurse narrative nursing note
Rubric designed to evaluate the end of clinical/shift note completed by level one nursing students
Rubric Code:
F236CA9
By
jramos_ramos
Ready to use
Public Rubric
Subject:
Nursing
Type:
Writing
Grade Levels:
Undergraduate
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Narrative Note Grading Rubric
Exceptional
4 pts
Above Average
3 pts
Average
2 pts
Below Average
1 pts
Subjective assessment is fully expl
Exceptional
Subjective assessment of health status is fully developed and linked to the reason for presentation with relevant information
Note specific and detailed
AMAZING WORK!
Above Average
Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.
GREAT JOB!
Average
Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes some irrelevant information.
GOOD JOB!
Below Average
Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem.
There was Irrelevant information is the main theme for the assessment.
GOOD TRY!
Objective assessment is fully expli
Exceptional
Objective assessment of health status is fully developed
Physical exam includes vital signs, height and weight and any relevant data related to full head to toe assessment of patient.
Above Average
Objective assessment is missing an element needed for adequate evaluation of the patient's problem.
Includes irrelevant information in assessment of head to toe evaluation
Average
Two or more elements needed for evaluation of a patient's problem is missing from the subjective and/or objective assessment.
Below Average
Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/or inappropriate for the presenting problem.
Documentation is clear and well org
Exceptional
Documentation is clear and well organized.
Appropriate medical terminology is used.
Format follows a standard, clean
Above Average
Documentation meets criteria for "exceptional" but there is occasional repetition of working or phrases.
Some documentation errors.
Average
Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence.
Difficult to read documentation
Below Average
Documentation does not meet expectations for this level as evidenced by either of the following:
lay terminology, illogical sequencing, missing essential elements.
Plagiarism noted from other health care provider notes.
First Morning Note
Exceptional
Documentation is clear and well organized.
Appropriate medical terminology is used.
Repetitious words, phrases, and other distracting information are omitted. "first look" and safety format follows a standard and has a logical flow.
Above Average
Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format
Average
Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from findings making it difficult for the reader
Below Average
Documentation does not meet expectations for this level.
More than few grammatical errors
Documentation very much strays from the findings and make it very difficult for the reader
Plagiarism noted from other health care provider notes.
Subjects:
Medical
Nursing
Types:
Assignment
Writing
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