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iRubric: EHR Charting Rubric

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EHR Charting Rubric EHR Charting Rubric EHR Charting Rubric Code: J2473C6 By Ms_Sigel_RN Ready to use Public Rubric Subject: Medical Type: Assignment Grade Levels: Undergraduate

EMR Charting Category/Explanation
	Novice Doesn't yet see the picture 1 pts	Beginner Sees part of the picture 2 pts	Competent Sees the basic picture 3 pts	Proficient Sees the big picture 4 pts	Advanced Anticipates the changing picture 5 pts	Total Score Total Score for this column. (N/A)
Patient Information 5 pts Name DOB	Novice No items reviewed with patient	Beginner Only one item reviewed with patient.	Competent Only two items reviewed with patient.	Proficient All items reviewed with patient.	Advanced All items reviewed with patient and Updated appropriately in record.	Total Score
Pt. Summary Page Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Labs/Results 5 pts Most recent labs pertinent to diagnosis	Novice Reports lab data.	Beginner Distinguishes between normal and abnormal lab data/diagnostic studies.	Competent Uses understanding of lab values/studies to plan care.	Proficient Analyzes trends in lab values; compares with patient response.	Advanced Monitors patient response via analysis of lab data and exam; assists with plan for future testing.	Total Score
Pt. Summary Page Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
History 5 pts Past Medical History Family Medical History Social History	Novice Recalls questions for basic history data with guidance/prompts.	Beginner Discriminates between normal and abnormal history data.	Competent Gathers a complete and accurate history Uses understanding of disease process to focus questions during data gathering.	Proficient Includes family history to develop comparison with current condition.	Advanced Anticipates potential outcomes based on history findings.	Total Score
Pt. Summary Page Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Complaint 5 pts CC and/or Primary diagnosis Secondary diagnosis	Novice Documented poorly.	Beginner Documented without explanation.	Competent Documented and explained.	Proficient Documented and well- described with onset, time, and adequate descriptors.	Advanced Documented well and describes onset, palliation, quality, radiation, severity, and time with descriptive details. Lists patient education.	Total Score
Pt. Summary Page Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Allergies 5 pts Review of patient allergies	Novice No information listed; no documentation	Beginner Some information is listed but no documentation of verifying allergies with patient.	Competent Information is complete; Documented the verification of allergy with patient.	Proficient Information is complete and well organized. Documented the verification of allergy with patient. Describes allergic response to allergen.	Advanced Information is complete and well organized. Documented the verification of allergy with patient. Describes allergic response to allergen. Notes how long allergy has been identified and when the last onset occurred.	Total Score
Pt. Summary Page Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Vital Signs 5 pts Lists vital signs obtained throughout shift	Novice 1) Vital signs are incomplete and do not include all of the following components at minimum: BP, temperature, pulse, respiratory rate. 2) Only one set of vital signs are documented.	Beginner 1) Vital signs are incomplete and do not include all of the following components at minimum: BP, temperature, pulse, pulse rhythm, respiratory rate, effort, GCS, pt position 2) Only one set of vital signs are documented.	Competent Vital signs are complete and include all of the following components at minimum: BP, temperature, pulse, pulse rhythm, respiratory rate, effort, GCS, pt position 2) Only one set of vital signs are documented.	Proficient 1) Vital signs are complete and include all of the following components at minimum: BP, temperature, pulse, pulse rhythm, respiratory rate, effort, GCS, pt position 2) Additional VS components are documented as applicable: SPO2, SPO2 qualification, ETCO2, pain scale, blood glucose (AMS, diabetic, critical child), stroke scale, RTS 3. A minimum of 2 sets of vital signs are documented. 4) Vital signs are not documented after medication treatments.	Advanced 1) Vital signs are complete and include all of the following components at minimum: BP, temperature, pulse, pulse rhythm, respiratory rate, effort, GCS, pt position 2) Additional VS components are documented as applicable: SPO2, SPO2 qualification, ETCO2, pain scale, blood glucose (AMS, diabetic, critical child), stroke scale, RTS 3) A minimum of 2 sets of vital signs are documented. 4) Vital signs are documented after all medication treatments.	Total Score
Category Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Prescription 5 pts Update and Review of patient medications	Novice None documented No basis to assess	Beginner 1)Inappropriately documented 2) Medication documentation is incomplete 3) Does not demonstrate anticipation, assessment or ability to manage pain	Competent 1) Appropriately documented 2) Medication documentation is complete but includes all of the following starred components at minimum: Accurate times, crew, medication, route, *dosage, pt response 3) Demonstrates knowledge & adequate administration of common protocols	Proficient 1) Appropriately documented & reviewed with patient 2) Medication documentation is complete and includes all of the following starred components at minimum: Accurate times, crew, medication, route, *dosage, pt response 3) Links medication to diagnosis 4)Usually assesses and monitors pain or anticipated discomfort; knowledge & choice of protocols is accurate	Advanced 1) Appropriately documented & reviewed with patient 2) Medication documentation is complete and includes all of the following components at minimum: Accurate times, medication, route, dosage, pt response 3) Links medication to diagnosis 4) Usually assesses and monitors pain or anticipated discomfort; knowledge & choice of protocols is accurate 5) Lists non-pharmacological teaching/patient education.	Total Score
Flowsheets Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Assessment 5 pts Head to Toe Resident Data Assessment	Novice Performs assessment with guidance/prompts	Beginner Distinguishes between abnormal and normal assessment findings	Competent Recognizes changes in patient condition, intervenes appropriately, and reassesses	Proficient Classifies relative importance of multiple assessment findings over time	Advanced Relates ongoing findings to potential complications; modifies plan and nursing interventions based on findings	Total Score
Flowsheets Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Daily Care 5 pts ADL's, Hygiene, etc.	Novice Does not perform daily care; does not document any daily care.	Beginner Performs portions of daily care routine; omits at least one hygiene practice from care or from documentation.	Competent Performs and documents oral care, bathing process, ADL's, and shaving.	Proficient Performs and documents each oral care, bathing process, ADL's, and shaving (checking for anticoagulants before shaving with a bladed razor). 2) Documents patient response.	Advanced 1) Performs and documents each oral care, bathing process, ADL's, and shaving (checking for anticoagulants before shaving with a bladed razor), and any findings during care. 2) Documents patient response. 3) Distinguishes daily care findings; notes any irregularities and to whom it was reported to.	Total Score
Flowsheets Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Intake and Output 5 pts Fluid measurements in/out Food percentage intake Elimination measurements	Novice Omits two or more of the following: Fluid measurements in/out; Food percentage intake;Elimination measurements	Beginner Omits one of the following: Fluid measurements in/out; Food percentage intake;Elimination measurements	Competent Adequately documents Fluid measurements in/out; Food percentage intake;Elimination measurements	Proficient Consistently documents Fluid measurements in/out; Food percentage intake;Elimination measurements Records patient response.	Advanced Consistently documents Fluid measurements in/out; Food percentage intake;Elimination measurements including patient tolerance/difficulties; any issues noted and to whom it was reported.	Total Score
Flowsheets Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Interventions/Wounds 5 pts Lists wounds and descriptions. Indicates if none found.	Novice Does not indicate whether patient has wounds or not.	Beginner Indicates wounds but only notes where they are located; provides no details on stage or description.	Competent Indicates wounds, location; provides details on size/depth, and staging.	Proficient Indicates wounds, location; provides details on size/depth, and staging/edges. Notes drainage, if any, and uses appropriate medical terminology to describe wound bed/granulation and staging/drainage.	Advanced Indicates wounds, location; provides details on size/depth, and staging/edges. Notes drainage, if any, and uses appropriate medical terminology to describe wound bed/granulation and staging/drainage. 2) Includes current treatment plan and patient response to treatments performed and the healing r/t treatment choice.	Total Score
Flowsheets Category/flow sheet/tab
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Care Plans 5 pts Enters Nursing Diagnosis Statement, Goals, Interventions, Rationale, Evaluation	Novice One or more critical components is missing.	Beginner All critical components are present; but uses textbook examples that do not relate to each other. Planning/Goals are not patient oriented and may not have measurable criteria/target date.	Competent All critical components are present and relate back to the patient. Planning/Goals are patient oriented with appropriate criteria/target dates. Interventions are adequate and specific.	Proficient All pertinent data is present, appropriate for the patient, NANDA approved, and is listed in correct order. Data provides accurate depiction of patient. Planning/Goals are patient oriented with appropriate criteria/target dates. Interventions are adequate and specific. Details provided regarding patient education.	Advanced All pertinent data is present, appropriate for the patient, NANDA approved, and is listed in correct order. Data provides accurate depiction of patient. Planning/Goals are patient oriented with appropriate criteria/target dates. Interventions are adequate and specific. Details provided regarding patient education and plan for discharge.	Total Score
Notes Narrative Shift Charting
	Novice Doesn't yet see the picture (N/A)	Beginner Sees part of the picture (N/A)	Competent Sees the basic picture (N/A)	Proficient Sees the big picture (N/A)	Advanced Anticipates the changing picture (N/A)	Total Score Total Score for this column. (N/A)
Narrative Shift Charting 5 pts Has entries no less than every 2 hours.	Novice Documentation is not clear and Documentation does not meet expectations for this level as evidenced by either of the following: lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.	Beginner Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format from logical sequence for head to toe documentation but the reader is able to determine findings with difficulty. Contains up to 2 errors.	Competent Documentation meets criteria for clarity. Documentation is clear and does not stray from standard format from logical sequence for head to toe documentation. All required components are present. May contain one minor error.	Proficient Documentation meets criteria for clarity. Documentation is clear and does not stray from standard format from logical sequence for head to toe documentation. All required components are present. Contains no errors.	Advanced Documentation is clear and well organized. Brevity and Precision are present. Appropriate medical terminology is used. Redundant (repetitious) words, phrases, and other distracting information are omitted. Format follows a standard. Narratives for head to toe and follow up notes have a logical flow. No errors. Charts no less than every 2 hours.	Total Score
TOTAL 0 pts	Novice Total for all columns entered to far right	Beginner Total for all columns entered to far right	Competent Total for all columns entered to far right	Proficient Total for all columns entered to far right	Advanced Total for all columns entered to far right	Total Score Total for all columns: ___________________

Keywords:

EMR Charting

Subjects:

Medical

Types:

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