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iRubric: Physical Exam finding documentation Rubric

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Physical Exam finding documentation Rubric Physical Exam finding documentation Rubric Physical exam rubric Rubric Code: QX96946 By klevitas Ready to use Public Rubric Subject: Medical Type: Writing Grade Levels: Graduate

Physical Exam Rubric
	Poor 1 pts	Good 3 pts	Excellent 5 pts
Organization	Poor No logical organization. Not in a head to toe fashion. Most of the systems are not in the correct documentation order of Inspection, Percussion, Palpation, Auscultation, Special tests. Order is not altered when appropriate.	Good Fairly logical sequence of information. May be some deviation of a 1-3 systems out of head to toe order. Most of the systems are in the correct documentation order of Inspection, Percussion, Palpation, Auscultation, Special tests. Order altered when appropriate.	Excellent Clearly organized in a head to toe fashion. Each body system evaluated is documented in a logical sequence of Inspection, Percussion, Palpation, Auscultation, Special tests. Order altered when appropriate.
Content	Poor Only a few if any of the systems are thoroughly and clearly documented Several of the tests are omitted in more than 3 systems.	Good Most of the systems are thoroughly and clearly documented. 1 or more tests are omitted in 1- 3 systems.	Excellent Thoroughly and clearly documents each test performed for each system. No tests are omitted or only a small omission in lesss than 1-3 systems in noted.
Accuracy	Poor Multiple inaccurate statements. More than 1/3 of the tests were performed incorrectly and/or documented incorectly	Good Acceptable accuracy. Most of the tests were performed correctly and documented correctly	Excellent Comprehensively accurate. Tests performed for each system were performed correctly and documented correctly
Medical term./Grammar/Punctuation	Poor Poor grammar and punctuation impeded value of documentation; medical terminology used was used incorrectly.	Good Grammar and punctuation were acceptable; medical terminology was usually correct.	Excellent Excellence of grammar, punctuation, and medical terminology that enhances the value of the documentation.