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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
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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
Keywords:
file, chart, quality, review, psychiatry
Subjects:
Medical
Types:
(Other)
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