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iRubric: Consult: History rubric

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Consult: History History Appropriate (DRAFT 2) For use in quality review of psychiatric records. Rubric Code: RX8C5C4 By lmyronuk Ready to use Public Rubric Subject: Medical Type: (Other) Grade Levels: Graduate, Post Graduate

Outpatient Chart Review History
	Unacceptable Red 0 pts	Needs improvement Red 1 pts	Acceptable Yellow 2 pts	Good Green 3 pts
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