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iRubric: Patien Care Report QA/QI Review rubric

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Patien Care Report QA/QI Review Patien Care Report QA/QI Review PCR Rubric: Use for QA/QI purposes during the review of Medical Reports/Patient Care Reports Rubric Code: QXC98WX By bplatt78 Draft Public Rubric Subject: Medical Type: Assessment Grade Levels: (none)

PCR QA/QI Review Enter rubric description
	Poor 1 pts	Fair 2 pts	Good 3 pts	Very Good 4 pts	Excellent 5 pts
Incident Response & Patient Information: Patient demographics including Name, Address, Phone, DOB, Age, Sex, Race, etc.	Poor No patient demographics listed without adequate explanation documented in PT Narrative. Incident numbers/times incomplete/incorrect.	Fair Partial PT demographics. Incomplete information without adequate explanation documented in PT Narrative. Partial Incident numbers/times.	Good Adequate PT demographics. Includes Name, Address, Phone, DOB. Adequate Incident numbers/times. Includes ALS Arrival time.	Very Good All PT demographics documented including Name, Address, Phone, DOB, Age, Sex, Race, etc. Adequate Incident numbers/times Includes ALS Arrival time.	Excellent All PT demographics documented including Name, Address, Phone, DOB, Age, Sex, Race, etc. Adequate Incident numbers/times Includes PT Contact time, ALS Arrival time, and Transfer of Care time.
PT Assessment Elements Includes Chief Complaint, History, Medications, Allergies, Mental Status, LOC, History of Present illness/injury, Airway, Physical Assessment (position found, appearance, pertinent negatives), Vital Signs, Diagnostics.	Poor No PT assessment elements documented. No adequate explanation of missing assessment documented in PT Narrative.	Fair Partial PT assessment. Incomplete information without adequate explanation documented in PT Narrative.	Good Adequate PT assessment documented. Includes Chief Complaint, History, Medications, Allergies, LOC, Airway assessment. Incomplete vital signs/Diagnostics without explanation.	Very Good Complete PT assessment documented. Includes Chief Complaint, History of Present Illness/Injury, History, Medications, Allergies, LOC, Airway assessment. Complete set of Vital Signs/Diagnostics.	Excellent Complete PT assessment documented. Includes Chief Complaint, History of Present Illness/Injury, History, Medications, Allergies, LOC, Airway assessment. Complete set of Vital Signs/Diagnostics.
Enter title Enter description	Poor	Fair	Good	Very Good	Excellent