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iRubric: Inpatient Consult Rotational Clinical Assessment rubric

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Inpatient Consult Rotational Clinical Assessment Inpatient Consult Rotational Clinical Assessment This rubric is designed for the assessment o fresidents during their Inpatient Consult rotations at NYPH CPC and WCC Rubric Code: SXAAA33 By janemariesouza Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: Post Graduate

I. History
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 12.5 pts	Exceptional 20 pts
Chief Complaint (CC) and HPI	Not Observed	Unacceptable Chief Complaint and History of Present Illness is scant. The majority of vital information to the chief complaint is missing.	Marginally Acceptable Chief Complaint and History of Present Illness is age appropriate, however is missing some vital information relevant to the chief complaint. It is not logically written.	Satisfactory Chief Complaint and History of Present Illness is age and rehab appropriate if applicable. Some non-vital information relevant to chief complaint is missing. It is written in a logical format.	Exceptional Chief Complaint and History of Present Illness is complete ;age and rehab appropriate. It is written in a logical format.
II. History II
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 7.5 pts	Exceptional 10 pts
Past Medical History I (PMH)	Not Observed	Unacceptable Complete Past Medical History is missing.	Marginally Acceptable Past Medical History is incomplete. There are key components missing from: Medical illnesses and hospitalizations; Surgeries, Functional Hx	Satisfactory Past Medical History complete however there are missing key components from: Medical illnesses and hospitalizations; Surgeries, Functional Hx	Exceptional A complete Past Medical History is present and contains:Medical illnesses and hospitalizations; Surgeries, Functional HX complete
History II
	Not Observed (N/A)	Unacceptable 0 pts	Marginally acceptable 5 pts	Acceptable 7.5 pts	Exceptional 10 pts
Past Medical History II	Not Observed	Unacceptable Complete Past Medical History is missing.	Marginally acceptable Two components of the complete past medical history are missing or the components are incomplete: Current medications, allergies, social history.	Acceptable One component of the complete past medical history is missing or the components are incomplete: Current medications, allergies, social history. x	Exceptional A complete history is present regarding current medications, allergies, social history.
III. Physical Examination
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 7.5 pts	Satisfactory 15 pts	Exceptional 20 pts
Physical Examination	Not Observed	Unacceptable The physical examination is missing or grossly incomplete.	Marginally Acceptable Four components of the physical examination are missing: Vital Signs including BMI General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.	Satisfactory Two components of the physical examination are missing: Vital Signs including BMI General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.	Exceptional All components of the physical examination are present: Vital Signs including BMI General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.
IV. Labs/Diagnostics/Problem List
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 10 pts	Exceptional 15 pts
Labs/Diagnostic Tests	Not Observed	Unacceptable There are no mention of laboratory testing or diagnostic imaging.	Marginally Acceptable Some of the appropriate labs and diagnostic studies have been addressed. Abnormal findings are not flagged as high (H) or low (L).	Satisfactory All appropriate labs and diagnostic studies are recorded. Abnormal findings are not flagged as high (H) or low (L).	Exceptional All appropriate labs and diagnostic studies are recorded. All abnormal findings are flagged as high (H) or low (L).
V. Assement and Plan
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 7.5 pts	Satisfactory 15 pts	Exceptional 25 pts
Assessment and Plan	Not Observed	Unacceptable The diagnosis(s), assessments, or treatment plan is not documented. Does not follow evidence based medicine	Marginally Acceptable The assessment lists the chief complaint but is missing other problems. The treatment plan is incomplete for the complaints presented. Some follow of evidence based medicine.	Satisfactory The assessment lists the chief complaint but one or more problems is missing. The treatment plan is complete for the complaints presented and follows evidence based medicine.	Exceptional The assessment lists ALL of the pertinent problems for the patient, not just the chief complaint. The plan is ordered properly and follows evidence based medicine, is appropriate for the patient and demonstrates a logical progression of knowledge.
VI. Procedural Skills
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Aceptable 5 pts	Satisfactory 7.5 pts	Exceptional 10 pts
Procedural Skills	Not Observed	Unacceptable Difficulty using proper technique; awkward with equipment or bypasses accepted steps; timing, coordination and/or organization are faulty. Technique places self/patient at risk.	Marginally Aceptable Some difficulty using proper technique; sometimes fails to organize equipment before procedure; occasional problems with timing or coordination.	Satisfactory Some difficulty using proper technique; sometimes fails to organize equipment before procedure; occasional problems with timing or coordination.	Exceptional Timing is precise; procedures performed with ease and dexterity. Able to put patient at ease.
VII. Medical Knowledge
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 7.5 pts	Exceptional 10 pts
Medical Knowledge	Not Observed	Unacceptable Poor recall of basic science, pathophysiology & clinical information; cannot relate it to cases.	Marginally Acceptable Has basic knowledge of disease processes & pathologic events; some ability to relate information to clinical material.	Satisfactory Above average knowledge relevant to assigned patients; able to correlate this knowledge consistently with clinical material.	Exceptional Superior knowledge with mature application to clinical setting; able to evaluate/apply recent literature.
VIIIDifferential Diagnosis and Prob
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 2.5 pts	Satisfactory 7.5 pts	Exceptional 10 pts
Diff Dx and Problem Solving	Not Observed	Unacceptable Unable to integrate elements of a clinical knowledge base; has only rudimentary problem-solving ability. Cannot generate problem list or differential diagnosis.	Marginally Acceptable Somewhat awkward in integrating elements of a clinical knowledge base. Can generate short list of appropriate differential diagnoses for assigned patients.	Satisfactory Able to synthesize many aspects of the clinical knowledge base into a differential diagnosis and plan that is supported by basic evidence-based standards.	Exceptional Produces sophisticated differential diagnoses and plans; synthesizes patient's problems according to priority.. Diagnostic reasoning and testing strategies are astute.
IX. Practice based Learning & Imprv
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 10 pts	Exceptional 15 pts
Practice based Learning & Improvmnt	Not Observed	Unacceptable Little evidence of assigned or supplemental reading. Cannot accept constructive criticism. Fails to share knowledge with others.	Marginally Acceptable Completes reading and study assignments. Accepts feedback when offered. Takes responsibility for own actions. Will offer information when solicited.	Satisfactory Does some supplemental as well as assigned reading. Actively solicits and incorporates feedback. Volunteers information with peers.	Exceptional Self-motivated to expand knowledge; intellectually curious. Seeks advice and consultation when needed. Is self-reflective. Takes active role in sharing information with peers. Contributes to teaching efforts on the service
X INTERPERSONAL AND CO
	Not Observed (N/A)	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 10 pts	Exceptional 15 pts
INTERPERSONAL AND CO	Not Observed	Unacceptable Student communicates poorly with patients. Written clinical encounters records are incomplete, poorly organized, or illegible. Student fails to keep appropriate records. Oral presentations are disorganized & poorly integrated.	Marginally Acceptable Student utilizes basic communication strategies. Written clinical encounters records are occasionally incomplete or disorganized. Oral presentations generally organized, but verbose or incomplete.	Satisfactory Student utilizes appropriate communication strategies with patients. Written clinical encounters records cover primary problems in a complete and organized manner. Well-organized, coherent & complete oral presentations.	Exceptional Student communicates effectively with most patients. Written clinical encounters records are prompt, concise, accurate, thorough, relevant; important problems reported & adequately explained. Oral presentations are complete, concise, orderly & polished; intellectually polished; clear delineation of all clinical issues.
XI. PROFESSIONALISM
	Not Observed (N/A)	Unacceptable 0 pts	Marginally acceptable 5 pts	Acceptable 12.5 pts	Exceptional 20 pts
Professionalism	Not Observed	Unacceptable Insensitive to patients and families. Fails to recognize appropriate boundaries with patients. Lacks sensitivity to patient individuality. Insensitive to cultural diversity as well as to individual privacy of information.	Marginally acceptable Sometimes has difficulty establishing rapport with patients and families. Sometimes recognizes importance of patient individuality.	Acceptable Relates well to most patients and family members. Demonstrates sensitivity and responsiveness to patient individuality.	Exceptional Demonstrates sensitivity and responsiveness to patient individuality. Consistently demonstrates respect, empathy and compassion for patients and families.
WORK HABITS & PERSONAL ACCOUNTABILI
	Not Observed (N/A)	Unacceptable 0 pts	Marginally acceptable 10 pts	Acceptable 15 pts	Exceptional 20 pts
WORK HABITS & PERSONAL ACCOUNTABILI	Not Observed	Unacceptable Poor attendance; shirks responsibilities; disorganized. Frequently late. Fails to assume appropriate share of team work. Lacks accountability Fails to recognize or address personal limitations.	Marginally acceptable Attends required functions; assumes expected responsibilities. Demonstrates accountability to patients, peers and team members. Can recognize personal limitations	Acceptable Occasionally attends extra functions; independent initiative; well organized. Strong sense of accountability to patients peers and team members. Recognizes and addresses personal limitations	Exceptional Regularly attends extra functions; assumes leadership roles Strong sense of accountability to patients, peers and team members. Recognizes and addresses personal limitations and has the ability to be self reflective

Keywords:

Residents

Subjects:

Medical

Types:

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