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iRubric: H&P - History Documentation Rubric
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H&P - History Documentation Rubric
H&P - History Documentation Rubric
Rubric Code:
HX63W99
By
mtucker01
Ready to use
Public Rubric
Subject:
Medical
Type:
Assessment
Grade Levels:
Graduate
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History Documentation Rubric
Exceeds Expectations
5 pts
Meets Expectations
4 pts
Needs Improvement
3 pts
Unacceptable
2 pts
Did Not Attempt
0 pts
Organization/Clear Communication
Exceeds Expectations
Content is clear and well organized in a logical sequence; follows acceptable format
Meets Expectations
Content is mostly clear and generally organized in logical sequence; follows acceptable format
Needs Improvement
Content is somewhat confusing and disorganized with errors in format
Unacceptable
Content is confusing and disorganized with multiple errors in format
Did Not Attempt
Thoroughness of documented history
Exceeds Expectations
History includes:
1. CC
2. HPI, including all PQRST attributes
3. Meds/ Allergies
4. PMH 5. PSH
6. FH 7. SH 8. ROS, including at least 10 body systems
Meets Expectations
History includes all 8 of the items listed, but omits 1-2 items within a section (ie, misses one body system in ROS)
Needs Improvement
History includes 6-7 of the items listed OR omits 3-4 items within a section
Unacceptable
History includes 1-5 of the items listed OR omits >4 items within a section
Did Not Attempt
Grammar
Exceeds Expectations
Virtually free of any errors in spelling and grammar
Meets Expectations
Free of significant errors in spelling and grammar. Errors present do not detract from the overall write-up
Needs Improvement
Several errors (3-4) in spelling and grammar
Unacceptable
Multiple errors (>4) in spelling and grammar
Did Not Attempt
Terminology
Exceeds Expectations
Used correct terminology consistently throughout write-up
Meets Expectations
Used incorrect terminology 1-2 times throughout write-up
Needs Improvement
Used incorrect terminology 3-4 times throughout write-up
Unacceptable
Used incorrect terminology >4 times throughout write-up
Did Not Attempt
Subjects:
Medical
Types:
Assessment
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