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iRubric: H&P Practical - Head and Neck rubric

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H&P Practical - Head and Neck Rubric Code: Q9536C By jenniferpack Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: (none)

Element
	Attempted Satisfactorily 3 pts	Attempted - Needs Improvement 2 pts	Attempted - Unacceptable 1 pts	Did Not Attempt 0 pts	Score (N/A)
SKULL, SCALP, HAIR (HPE-7.1) Inspection	Attempted Satisfactorily Performed and verbalized assessment for: 1. Deformities 2. Tenderness 3. Scaliness 4. Quantity of Hair 5. Distribution of Hair 6. Texture of Hair	Attempted - Needs Improvement Performed and verbalized assessment of 4-6 areas	Attempted - Unacceptable Performed and verbalized assessment of 1-3 areas	Did Not Attempt Did not inspect and palpate skull, scalp, and hair	Score
EXTERNAL EYES (HPE-7.1) Inspection	Attempted Satisfactorily Inspected, verbalized bilateral assessment of: 1. Eyebrows 2. Eyelashes 3. Upper /Lower lids 4. Lacrimal apparatus 5. Conjunctiva 6. Sclera 7. Corneas 8. Pupils 9. Iris 10. Eye alignment - checked light reflex in both corneas	Attempted - Needs Improvement Inspected, verbalized assessment of 5-9 areas	Attempted - Unacceptable Inspected, verbalized assessment of 1-5 areas	Did Not Attempt Did not verbalize inspection of the eyes	Score
VISUAL ACUITY (HPE-7.1) CN II	Attempted Satisfactorily 1. Checked visual acuity using Snellen eye chart 2. Patient was correct distance from chart 3. Tested each eye individually 4. Documented findings	Attempted - Needs Improvement Checked visual acuity but patient was incorrect distance from the eye chart	Attempted - Unacceptable Examiner did not look at the eye chart for results or document findings, or did not test each eye individually	Did Not Attempt Did not check visual acuity	Score
PUPILLARY REACTION (HPE-7.1) CN III	Attempted Satisfactorily Tested both direct and consensual pupillary reaction to light. Paused between each test for pupil to return to normal size.	Attempted - Needs Improvement Did not pause an adequate amount of time for pupil to return to normal size	Attempted - Unacceptable Tested only direct or consensual pupillary reaction to light; not both	Did Not Attempt Did not assess pupillary reaction to light	Score
EOMs (CN III, IV, VI)	Attempted Satisfactorily 1. Tested EOMs using the "H" pattern 2. Verbalized assessment for nystagmus and convergence	Attempted - Needs Improvement Did not pause an adequate amount of time to assess for nystagmus or "H" pattern was performed too quickly to adequately assess. Or, omitted either assessment of nystagmus or convergence	Attempted - Unacceptable Did not assess or verbalize assessment for nystagmus and convergence	Did Not Attempt Did not assess EOM	Score
FUNDOSCOPIC EXAM (HPE-7.1) CN II	Attempted Satisfactorily 1. Explained procedure to the patient 2. Dimmed the lights 3. Held Opthalmoscope in correct hand and used the correct eye for examination 4. Used a mechanism to avoid getting too close to the patient or losing balance 5. Was close enough to patient to adequately examine the fundus 6. Verbalized assessment of the vessels, optic disc, retina	Attempted - Needs Improvement Omitted or incorrectly performed 1-2 elements of the fundoscopic exam	Attempted - Unacceptable Omitted or incorrectly performed 3-4 elements of the fundoscopic exam	Did Not Attempt Omitted or incorrectly performed >4 elements of the fundoscopic exam	Score
EXTERNAL EARS (HPE-7.1) Inspection	Attempted Satisfactorily Inspected and verbalized assessment of both auricles for deformities and skin lesions	Attempted - Needs Improvement Inspected but did not verbalize what he/she was assessing	Attempted - Unacceptable Assessed unilaterally	Did Not Attempt Did not inspect the external ears	Score
OTOSCOPIC EXAM (HPE-7.1)	Attempted Satisfactorily 1. Gently pulled on auricle to straighten ear canal 2. Used a safety mechanism to avoid trauma to TM or ear canal (bracing finger) 3. Inspected and verbalized assessment of ear canal and tympanic membrane	Attempted - Needs Improvement Did not verbalize assessment of ear canal and TM or did not properly pull on the auricle	Attempted - Unacceptable Did not use a safety mechanism when examining the ear canal and TM	Did Not Attempt Did not do an otoscopic exam, or did not perform any of the required steps	Score
EXTERNAL NOSE (HPE-7.1) Inspection	Attempted Satisfactorily Inspected and verbalized assessment of external nose for asymmetry or deformity	Attempted - Needs Improvement Inspected and verbalized assessment of external nose; did not verbalize assessment of asymmetry OR deformity	Attempted - Unacceptable Inspected the external nose, but did not verbalize what he/she was assessing	Did Not Attempt Did not inspect the external nose	Score
NARES (HPE-7.1) Inspection	Attempted Satisfactorily 1. Inspected inside of nares with the otoscope, avoiding contact with the nasal septum 2. Verbalized assessment of nasal mucosa and nasal septum	Attempted - Needs Improvement Did not verbalize assessment of nasal mucosa OR nasal septum	Attempted - Unacceptable Did not avoid contact with the nasal septum OR did not verbalize assessment	Did Not Attempt Did not perform the nares examination OR did not avoid contact with septum AND did not verbalize assessment	Score
SINUSES (HPE-7.1) Palpation	Attempted Satisfactorily Palpated for sinus tenderness 1. Over the proper area 2. Pressed firmly, but not too hard	Attempted - Needs Improvement One area of palpation was slightly incorrect OR examiner did not apply correct amount of pressure	Attempted - Unacceptable Location of palpation was slightly incorrect for both areas OR completely incorrect for 1 area	Did Not Attempt Did not palpate sinuses OR location of palpation was completely incorrect for both areas	Score
MOUTH (HPE-7.1)	Attempted Satisfactorily Inspected and verbalized assessment of: 1. Lips 2. Oral Mucosa 3. Gums and Teeth 4. Roof of Mouth 5. Tongue/Floor 6. Pharynx, using light and tongue blade to assess all areas	Attempted - Needs Improvement Thoroughly inspected and verbalized assessment of 4-6 areas of the mouth	Attempted - Unacceptable Thoroughly inspected and verbalized assessment of 1-3 areas of the mouth OR verbalized all areas, but did not assess thoroughly OR did not use a light and/or tongue blade	Did Not Attempt Did not examine the mouth, OR did not thoroughly inspect or verbalize any areas	Score
TONGUE, PHARYNX, GAG (HPE-7.1) CN IX, X, XII	Attempted Satisfactorily 1. Asked patient to stick out his/her tongue and move it from side to side 2. Asked the patient to say "Ah" while using a tongue blade and light to examine the pharynx 3. Elicited a gag reflex using the tongue blade	Attempted - Needs Improvement Performed 2 of the tasks properly	Attempted - Unacceptable Performed 1 task properly	Did Not Attempt Did not test CN IX, X, or XII or did not perform any of the tasks properly	Score
CRANIAL NERVE VII (HPE-7.1) CN VII	Attempted Satisfactorily Asked patient to: 1. Raise eyebrows 2. Frown 3. Had patient close eyes tightly and tried to pry them open 4. Show upper and lower teeth 5. Smile 6-Puff out both cheeks	Attempted - Needs Improvement Asked patient to perform 4-5 of the tasks	Attempted - Unacceptable Asked patient to perform 1-3 of the tasks	Did Not Attempt Did not assess the facial nerve	Score
SPINAL ACCESSORY NERVE (HPE-7.1) CN XI	Attempted Satisfactorily 1. Asked patient to shrug both shoulders upward against examiners hands 2. Asked patient to turn his/her head to each side against examiners hand	Attempted - Needs Improvement	Attempted - Unacceptable Asked patient to either shrug shoulders against resistance OR turn head against resistance	Did Not Attempt Did not assess the spinal accessory nerve	Score
NECK (HPE-7.1) Inspection	Attempted Satisfactorily Inspected neck and verbalized assessment for tracheal position, symmetry, masses, scars, and an enlarged thyroid gland. Asked patient to swallow and offered water. Had patient slightly extend neck for inspection of thyroid gland	Attempted - Needs Improvement Inspected neck and verbalized 3-4 areas of assessment, with thyroid gland being included. Asked the patient to swallow and offered water.	Attempted - Unacceptable Inspected neck and verbalized 1-2 areas of assessment OR did not have the patient swallow	Did Not Attempt Did not inspect the neck	Score
TRACHEA / THYROID (HPE-7.1) Palpation	Attempted Satisfactorily Palpated the trachea for position and the thyroid gland 1. Neck slightly forward 2. Fingers of both hands on pts. neck with index fingers just below the cricoid cartilage 3. Asked pt. to sip water, 4. Displaced trachea to one side, examining opposite lobe of gland, repeated on opposite side	Attempted - Needs Improvement Palpated the trachea for position and the thyroid gland, correctly performing 3 of the steps of the thyroid examination	Attempted - Unacceptable Palpated for tracheal position and the thyroid gland, correctly performing 1-2 of the steps of the thyroid examination OR correctly performed 3-4 of the steps of the thyroid examination AND did not palpate for tracheal position	Did Not Attempt Did not palpate for trachea position or the thyroid gland or performed incorrectly	Score
LYMPH NODES (HPE-7.1)	Attempted Satisfactorily Palpated correct location and verbalized: 1. Preauricular 2. Posterior auricular 3. Occipital 4. Tonsillar 5. Submandibular 6. Submental 7. Superficial cervical 8. Posterior cervical 9. Deep cervical 10 Supraclavicular	Attempted - Needs Improvement Palpated correct location and verbalized assessment of 7-9 cervical lymph nodes areas	Attempted - Unacceptable Palpated correct location and verbalized assessment of 4-6 cervical lymph node areas	Did Not Attempt Palpated correct location and verbalized assessment of <3 cervical lymph node areas	Score
CN V CN V Motor and Sensory	Attempted Satisfactorily Motor: Palpated masseter and temporal muscles while patient clenched teeth Sensory: Tested light and sharp touch bilaterally	Attempted - Needs Improvement	Attempted - Unacceptable Tested only motor or sensory function, but not both, OR, technique wrong on both	Did Not Attempt Did not test CN V	Score

Subjects:

Medical

Types:

Assessment

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