iRubric: History and Physical Assessment rubric

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History and Physical Assessment

History and Physical of patient in Western Clinical Medicine

Rubric Code: F943BB

By olsonj0218

Ready to use

Public Rubric

Subject: Medical

Type: Exam

Grade Levels: Graduate

Health and Physical Assessment
	Failing 0 pts	Fair 2 pts	Good 3 pts	Very Good 4 pts
Essential Tasks 20 % 1. Introduces self 2. Identifies patient 3. Washes Hands 4. Determines existence of allergies, medications, herbal preps, etc	Failing Students fails to perform 2 or more required tasks	Fair	Good	Very Good Student performs all required tasks
General Physical Assessment 20 % 1. Obtains the Chief Complaine 2. Asks the appropriate questions related to the the CC and expands the HPI 3. Gathers pertinent past medical history, ROS, Family, Psychosocial 4. Performs Physical Exam Using the appropriate techniques of a. Inspection b. Palpation c. Percussion d. Auscultation	Failing Inadequate history taking, fails to gather pertinent positive negatives, ROS, or important PMHx, Social, etc. Inadequate assessment performed	Fair Student performs marginally effective assessment	Good Student performs efficient assessment of assigned body system with minor omissions in technique, teaching, or performance.	Very Good 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.
Reporting 20 % Report should have following components: SUBJECTIVE 1. Biographical Sketch 2. Chief complaint or reason for visit 3. Patient Hx using initals and no identifying number 4. Previous illnesses and/or surgeries 5. Narrative Review of System OBJECTIVE 1. Results of physical exam. 2. Any followup action plan or tests	Failing Students narrative and or written is inadequate with gross deficiencies	Fair Student fails to address all elements in detail during presentation or has significant grammatical and spelling errors in case repot	Good Student addresses all key elements in narrative with minor grammatical errors, spelling, or fomatting errors.	Very Good Student effectively correctly addresses every key element of the assessment in a narrative having the proper format with no grammatical or spelling errors.
Communication 20 % Effective professional communication orally and in writing.	Failing Failure to communicate .	Fair Student does not explain assessment to patient or talks minimally to patient	Good Student explains the assessment as they are completing each step.	Very Good 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.
Clinical judgement 20 % Effective reasoning and deduction from available information	Failing Failure to reason	Fair Student does not reason effectively but tries to use logically the available information.	Good Student reasons with minor mistakes or not taking full advantage of available information to reach a presumptive diagnosis or course of action based on all available information.	Very Good Student reasons effectively and reaches a plausible presumptive diagnosis or course of action based on all available information.

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