iRubric: History and Physical Assessment rubric

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History and Physical Assessment

History and Physical of patient in Western Clinical Medicine

Rubric Code: MX36B6C

By orneryt

Draft

Public Rubric

Subject: Nursing

Type: Assessment

Grade Levels: Graduate

Health and Physical Assessment
	Incomplete 0 pts	Fair 3 pts	Good 5 pts
Essential Tasks 5 pts 1. Introduces self<BR> 2. Identifies patient<BR> 3. Washes Hands <BR> 4. Determines existence of allergies, medications, herbal preps, etc<BR> check vital signs,record height and weight	Incomplete Students fails to perform 2 or more <BR> required tasks<BR> <BR> <BR> <BR> <BR> points:0-3	Fair performs tasks with 2 <BR> omissions<BR> <BR> <BR> <BR> <BR> <BR> points: 6-4	Good performs tasks with one omission <BR> <BR> <BR> <BR> <BR> <BR> points:9-7
Obtain history 5 pts 1. Obtains the Chief Complaine<BR> 2. Asks the appropriate questions related to the the CC and expands the HPI <BR> 3. Gathers pertinent <BR> family,past present , social, religion work, habits	Incomplete Inadequate history taking, fails to gather pertinent positive negatives, ROS, or important PMHx, Social, etc.<BR> <BR> <BR> points:	Fair misses to gather pertinent history like<BR> when the surgery was done , any investigational drugs,recreational drugs <BR> <BR> points:	Good .gathers pertinent information ,misses one or two data <BR> <BR> <BR> <BR> <BR> <BR> <BR> points:
professional attitude 5 pts Effective professional communication orally and in writing.	Incomplete Failure to communicate .	Fair Student does not explain assessment to patient or talks minimally to patient	Good Student explains the assessment as they are completing each step.
Neuro Assessment 5 pts	Incomplete	Fair	Good
Pulmonary Assessment 5 pts	Incomplete	Fair	Good
Cardiovascular 5 pts	Incomplete	Fair	Good
Gastrointestional 5 pts	Incomplete	Fair	Good
Gastrourinary 5 pts	Incomplete	Fair	Good
Musculoskeletal 5 pts	Incomplete	Fair	Good