iRubric: HPI Assignments - Fall 2015 rubric

Incomplete

Date, time, patient initials, DOB, gender

HPI is missing >3 key components of OLDCARTS or any specialized history warranted for the CC. Pertinent ROS missing 3 or more components.

HPI is missing 2-3 components of OLDCARTS and some pertinent specialized history related to the CC is missing. Pertinent ROS is missing 2 or more components.

HPI is missing 1-2 components of OLDCARTS. Specialized history related to the CC is present, but not detailed enough. May be missing 1 or more pertinent ROS and/or last menstrual period is not included.

HPI is complete with all appropriate components of OLDCARTS presented as well as any necessary specialized history related to CC. Includes pertinent ROS to the CC. Last menstrual period is included.

Complete FH is missing.

FH is lacking most details or vaguely. addressed.

FH is complete but some details are lacking.

FH is complete with appropriate first degree relatives, ages, medical conditions, and/or deaths and cause of deaths.

Complete ROS is missing.

Three components of a complete ROS are missing or vaguely addressed, ROS contains extraneous or distracting pieces of information, and/or positive findings are not properly documented.

Two components of a complete ROS are missing or vaguely addressed. No distracting or extraneous information is included and positive findings are properly documented.

A complete ROS is present including: general, skin, head, eyes, ears, nose, mouth and throat, neck, breast (when appropriate) respiratory, cardiovascular, peripheral vascular, gastrointestinal, urinary, genital, gynecological (when appropriate), sexual, musculoskeletal, psychiatric, neurological, hematologic, and endocrine. Positive findings are properly documented.