iRubric: History Appropriate (DRAFT 2) rubric

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History Appropriate (DRAFT 2) Informed Consent Compliant DRAFT -2- For use in quality review of chiropractic clinical records. Rubric Code: L3XAA8 By JP_NYCC Ready to use Public Rubric Subject: Medical Type: (Other) Grade Levels: (none)

DC File Review History Appropriate
	Very poor Red 0 pts	Unacceptable Red 1 pts	Acceptable Yellow 2 pts	Good Green 3 pts	Exceptional Blue 4 pts
1. Chief Complaint(s)	Very poor Core components absent.	Unacceptable Lacks significant required information	Acceptable All significant data recorded but with little detail	Good Required elements recorded in reasonable detail	Exceptional All components thoroughly recorded with exceptional detail
2. Medical, Social, Family History	Very poor Relevant components not recorded.	Unacceptable Relevant components addressed but to insufficient degree	Acceptable All relevant components recorded adequately but with minimal detail	Good Relevant issues recorded with good detail	Exceptional All relevant components thoroughly recorded with exceptional detail
3. Review of Systems	Very poor Absent	Unacceptable Insufficient detail obtained regarding relevant systems	Acceptable Adequate investigation of relevant systems but with minimal detail	Good Reasonably detailed recording of relevant systems	Exceptional All relevant systems covered with exceptional detail