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iRubric: EHR Charting Rubric

iRubric: EHR Charting Rubric

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

Powered by iRubric 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:






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