iRubric: Narrative Nursing Notes Rubric

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Narrative Nursing Notes Rubric

Rubric designed to evaluate shift nursing notes by nursing students

Rubric Code: MX8A92X

By lyndseybailey

Ready to use

Public Rubric

Subject: Nursing

Type: Writing

Grade Levels: Undergraduate

Narrative Note Grading Rubric
	Exceptional 4 pts	Above Average 3 pts	Average 2 pts	Below Average 1 pts
Documentation	Exceptional Documentation is clear and well organized. Appropriate medical terminology is used. Redundant (repetitious) words, phrases, and other distracting information are omitted. Format follows a standard form with all necessary components included correctly. Narratives for follow up notes have a logical flow.	Above Average Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format of documentation or is missing 1 necessary component, but the reader is able to determine findings with minimal difficulty.	Average Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format of documentation or is missing 2 necessary components, but the reader is able to determine findings with difficulty.	Below Average 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.
Background/Situation	Exceptional Documentation is clear and well organized. Appropriate medical terminology is used. Redundant (repetitious) words, phrases, and other distracting information are omitted. Format follows a standard and has a logical flow.	Above Average Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format for documentation but the reader is able to determine findings with minimal difficulty.	Average Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format from logical sequence for documentation but the reader is able to determine findings with difficulty.	Below Average Documentation does not meet expectations for this level as evidenced by either of the following: does not clearly state the background of the situation, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Subjective assessment	Exceptional Subjective assessment of health status is fully explicated and targeted toward the reason for presentation without the inclusion of extraneous information. Assessment is fully developed and includes location, duration, timing, character, severity, or other features appropriate for the reason for presentation. Note is specific and detailed	Above Average Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.	Average Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.	Below Average Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment
Objective assessment	Exceptional Objective assessment of health status is fully explicated. Physical exam includes vital signs, height and weight for as appropriate, and any relevant data related to focused full head to toe assessment of patient.	Above Average Objective assessment is missing an element needed for adequate evaluation of the patient's problem. Includes irrelevant information in assessment of full focused head to toe evaluation	Average Two or more elements needed for adequate evaluation of a patient's problem is missing from the subjective and/or objective assessment.	Below Average Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/or inappropriate for the presenting problem.
Plan	Exceptional Documentation is clear and well organized. Appropriate medical terminology is used. Redundant (repetitious) words, phrases, and other distracting information are omitted. Plan is appropriate for the DX & accurately addresses the problem identified for evaluation/follow-up care without omission to assessment, plan, or education.	Above Average Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized. Reader is able to determine findings with minimal difficulty. Includes only 1 minor error in the application or omission of DX,plan, patient education, or follow-up	Average Documentation meets criteria for clarity but needs to be better organized, but the reader is able to determine findings with difficulty. Includes 2 or more errors in the application or omission of diagnosis, plan, patient education, or follow-up	Below Average 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.
Follow up notes	Exceptional Documentation is clear & well organized. Appropriate medical terminology & phrases. Redundant words & other distracting info. are omitted. Follow up to pain, prn meds, urgent situations, or abnormalities in head to toe assessment follow a standard & has logical flow. All follow up phone calls are documented correctly and in chronological order.	Above Average Documentation meets criteria for "exceptional" but there is occasional redundant/distracting info. Follow up plan is appropriate and meets above criteria but is "generic" occasionally strays from standard format for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. All phones calls are documented, but with 1 error in chronological order.	Average Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format from logical sequence for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. The reader is able to determine findings with difficulty. All phone calls are made but with multiple errors in chronological orders.	Below Average Incorrectly or fails to apply evidence-based guidelines to assesment, DX, plan, patient education, or follow-up. Does not meet expectations for this level as evidenced by either of the following: does not clearly show follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. Use of lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors. All necessary phone calls are not documented.

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