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iRubric: Consult: History rubric

iRubric: Consult: History rubric

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Consult: History

  Derived from rubric: History Appropriate (DRAFT 2)
built by lmyronuk

Rubric Code: RX8C5C4
For use in quality review of psychiatric records.
ready Ready to use    public Public Rubric

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Keywords: file, chart, quality, review, psychiatry
Categories: Subjects: Medical  
Types: (Other)  
Grade Levels: Graduate, Post Graduate

Powered by iRubric Outpatient Chart Review
History
  Unacceptable
0 pts Red
Needs improvement
1 pts Red
Acceptable
2 pts Yellow
Good
3 pts Green
1. Chief Complaint(s)
Unacceptable

Core components absent.
Needs improvement

Lacks significant required information
Acceptable

All significant data recorded but with little detail
Good

Required elements recorded in reasonable detail
2. History of Presenting Complaint
Unacceptable

Core components absent.
Needs improvement

Lacks significant required information
Acceptable

All significant data recorded but with little detail
Good

Required elements recorded in reasonable detail
3. Past Psychiatric History
Unacceptable

Relevant components not recorded.
Needs improvement

Relevant components addressed but to insufficient degree
Acceptable

All relevant components recorded adequately but with minimal detail
Good

Relevant issues recorded with good detail
4. Past Medical/Surgical History
Unacceptable

Relevant components not recorded.
Needs improvement

Relevant components addressed but to insufficient degree
Acceptable

All relevant components recorded adequately but with minimal detail
Good

Relevant issues recorded with good detail
5. Medication List
Unacceptable

Absent
Needs improvement

Some information but not complete
Acceptable

Complete list of prescribed medications and doses
Good

Complete list of prescription and OTC medications and doses, adherence noted
6. Review of Systems
Unacceptable

Absent
Needs improvement

Insufficient detail obtained regarding relevant systems
Acceptable

Adequate investigation of relevant systems but with minimal detail
Good

Reasonably detailed recording of relevant systems
7. Developmental & Social History
Unacceptable

Absent
Needs improvement

Lacks significant required information
Acceptable

All significant data recorded but with little detail
Good

Required elements recorded in reasonable detail



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