iRubric: Consult: Diagnosis rubric

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Consult: Diagnosis Diagnosis Appropriate DRAFT -2- For use in quality review of psychiatric records. Rubric Code: TX8B86A By lmyronuk Ready to use Public Rubric Subject: Medical Type: (Other) Grade Levels: Graduate, Post Graduate

Outpatient Chart Review Diagnosis Appropriate
	Unacceptable Red 0 pts	Needs improvement Red 1 pts	Acceptable Yellow 2 pts	Good Green 3 pts
1. Area(s) of Complaint	Unacceptable Chief complaint(s) not addressed	Needs improvement ROS and/or other relevant findings not addressed.	Acceptable	Good Diagnoses address all presenting complaints and other significant findings.
2. Nosology	Unacceptable Diagnosis inconsistent with findings.	Needs improvement Diagnosis at low level of understanding, restatement of complaint or not incorporating relevant data.	Acceptable Diagnosis consistent with finds and provides and adequate basis for management.	Good Diagnosis representative of all significant findings, includes basic etiologic formulation and differential diagnosis
3. Coding	Unacceptable No DSM diagnosis	Needs improvement DSM diagnosis not from current edition or concurrent disorders not coded	Acceptable DSM diagnosis at level of major category (no 4th or 5th digit)	Good Fully specified 4- and 5-digit DSM diagnoses with additional specifiers for all concurrent diagnoses; uses V-codes appropriately