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iRubric: Ob & Gyn Clerkship Clinical Presentation rubric

iRubric: Ob & Gyn Clerkship Clinical Presentation rubric

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Ob & Gyn Clerkship Clinical Presentation 
Ob & Gyn Clerkship Clinical Presentation
This rubric is designed for the assessment of Medical Students in developing patient assessment and treatment during their Ob & Gyn rotation at RBMC
Rubric Code: HXB77XX
By yhc263
Ready to use
Public Rubric
Subject: Medical  
Type: Assessment  
Grade Levels: Post Graduate

Powered by iRubric I. History
  Unacceptable

0 pts

Marginally Acceptable

5 pts

Satisfactory

10 pts

Exceptional

15 pts

Chief Complaint (CC) and HPI
15 pts

Unacceptable

Chief Complaint and History of Present Illness is scant. The majority of vital information to the chief complaint is missing.

Remediation Required
Marginally Acceptable

Chief Complaint and History of Present Illness is age appropriate, however is missing some vital information relevant to the chief complaint. It is not logically written.
Satisfactory

Chief Complaint and History of Present Illness is age and ob gyn appropriate if applicable. Some non-vital information relevant to chief complaint is missing. It is written in a logical format.
Exceptional

Chief Complaint and History of Present Illness is complete ;age and ob gyn appropriate. It is written in a logical format.
II. History II
  Unacceptable

0 pts

Marginally Acceptable

5 pts

Satisfactory

7.5 pts

Exceptional

10 pts

Past Medical History I (PMH)
10 pts

Unacceptable

Complete Past Medical History is missing.

Remediation Required
Marginally Acceptable

Past Medical History is incomplete. There are key components missing from: Medical illnesses and hospitalizations; Surgeries, OB/GYN;
Satisfactory

Past Medical History complete however there are missing key components from:
Medical illnesses and hospitalizations; Surgeries, OB/GYN;
Exceptional

A complete Past Medical History is present and contains:Medical illnesses and hospitalizations; Surgeries, OB/GYN;
Past Medical History II
10 pts

Current Medications
Allergies
Social History
Unacceptable

Complete Past Medical History is missing.

Remediation Required
Marginally Acceptable

Two components of the complete past medical history are missing or the components are incomplete: Current medications, allergies, social history.
Satisfactory

One component of the complete past medical history is missing or the components are incomplete: Current medications, allergies, social history.





x
Exceptional

A complete history is present regarding current medications, allergies, social history.
III. Physical Examination
  Unacceptable

0 pts

Marginally Acceptable

7.5 pts

Satisfactory

15 pts

Exceptional

20 pts

Physical Examination
20 pts

Unacceptable

The physical examination is missing or grossly incomplete.

Remediation Required
Marginally Acceptable

Four components of the physical examination are missing:
Vital Signs including BMI
General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.
Satisfactory

Two components of the physical examination are missing:
Vital Signs including BMI
General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.
Exceptional

All components of the physical examination are present:
Vital Signs including BMI
General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.
IV. Labs/Diagnostics/Problem List
  Unacceptable

0 pts

Marginally Acceptable

1.5 pts

Satisfactory

3.5 pts

Exceptional

5 pts

Labs/Diagnostic Tests
5 pts

Unacceptable

There are no mention of laboratory testing or diagnostic imaging.

Remediation Required.
Marginally Acceptable

Some of the appropriate labs and diagnostic studies have been addressed. Abnormal findings are not flagged as high (H) or low (L).
Satisfactory

All appropriate labs and diagnostic studies are recorded.
Abnormal findings are not flagged as high (H) or low (L).
Exceptional

All appropriate labs and diagnostic studies are recorded. All abnormal findings are flagged as high (H) or low (L).
V. Assement and Plan
  Unacceptable

0 pts

Marginally Acceptable

7.5 pts

Satisfactory

15 pts

Exceptional

20 pts

Assessment and Plan
40 pts

-assessment
-treatment plan
-rationale for choice
patient education
Unacceptable

The diagnosis(s), assessments, or treatment plan is not documented.

Remediation Required.
Marginally Acceptable

The assessment lists the chief complaint but is missing other problems. The treatment plan is incomplete for the complaints presented.
Satisfactory

The assessment lists the chief complaint but one or more problems is missing. The treatment plan is complete for the complaints presented.
Exceptional

The assessment lists ALL of the pertinent problems for the patient, not just the chief complaint. The plan is ordered properly and follows evidence based medicine, is appropriate for the patient and demonstrates a logical progression of knowledge.



Keywords:
  • Medical Student

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