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iRubric: EMS Chart review rubric

iRubric: EMS Chart review rubric

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EMS Chart review EMS Chart review Patient care report QI review Rubric Code: TXB45B4 By dwirth Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: Graduate

Patient Care Report
	Unacceptable 0 pts	Poor 1 pts	Fair 3 pts	Good 4 pts	Excellent 5 pts
PCR Review Reason:
Legibility/grammar/spelling	Unacceptable Unable to read	Poor Difficult to read	Fair Hand-written with errors	Good Typed/hand-written with spelling errors or invalid/confusing/unclear abbreviations and easy to read	Excellent Typed and easy to read, no spelling errors, no confusing or unclear abbreviations
Completeness - tells the story	Unacceptable Critical information is missing	Poor Important information is missing	Fair Some information is missing	Good Information is complete, may be disorganized	Excellent Information is complete and well organized, story flows
Chief Complaint/Reason for call	Unacceptable None Documented	Poor Documented poorly	Fair Documented but missing information	Good Documented and explained	Excellent Documented and well described, with onset, duration, and adequate descriptors
History	Unacceptable None documented	Poor Documented poorly	Fair Documented but missing some information	Good Documented and explained	Excellent Documented and well described with PMH, medications and allergies
Assessment	Unacceptable None documented	Poor Documented poorly, leaving out key pertinent positives and negatives	Fair Documented, but missing some pertinent information.	Good Documented with all pertinent information.	Excellent Documented with indications of extensive assessment including differential assessment. Also documents reassessment.
Clinical Impression	Unacceptable None documented.	Poor Documented poorly, leaving out key pertinent positives and negatives.	Fair Documented, but missing some pertinent information.	Good Documented with all pertinent information.	Excellent Documented with indications of extensive assessment including differential assessment. Also documents reassessment.
Treatment	Unacceptable None documented; no specific protocol being identified.	Poor Documentation indicates poor treatment modalities or treatment is documented poorly. Protocol used not clearly identified. Diagnostic testing (12 leads, fingersticks, capnography) not documented or attached as part of the PCR. Unable to match treatment documented with clinical impression.	Fair Documented but not followed by effects of treatment. Protocol used identified; diagnostic testing (12 leads, fingerstick, capnography) not complete or mis-interpreted or not attached to the PCR. Treatment documented follows clinical impression.	Good Appropriately documented treatment. Protocol used identified; diagnostic testing (12 leads, fingerstick, capnography) complete and attached to PCR. Treatment documented follows clinical impression.	Excellent Documented well, indicating appropriate treatment and describes effects of treatment. Protocol used identified and followed; Diagnostic testing (12 leads, fingersticks, capnography) documented completely, attached to PCR and treatment follows protocol. Treatment follows clinical impression.
Document Response to Treatment	Unacceptable None documented	Poor Response to treatment documented poorly or incompletely.	Fair Response to treatment documented without explanation; omissions of pertinent positives and negatives post treatment.	Good Response to treatment documented and explained, with appropriate positives and negatives.	Excellent Documented and well- described with onset, time, and adequate descriptors, pertinent positives and negatives.
DMO; if required or used	Unacceptable Required but not done	Poor Required and done, but inadequately - orders denied OR requested (not required), not done adequately and orders denied	Fair Required and done; documentation inadequate but orders obtained OR requested but not required, documentation inadequate and orders obtained.	Good Required and done; documentation adequate and orders obtained OR requested but not required, documentation adequate and orders obtained.	Excellent Required and done; documentation complete and descriptive; and orders obtained OR requested but not required, documentation complete and descriptive; and orders obtained.
Transport decision	Unacceptable Transport decision: i.e. priority and destination not documented	Poor Transport priority and/or destination decision inappropriate for clinical impression.	Fair Transport priority or destination decision not appropriately documented, does not concur with clinical impression.	Good Appropriate transport priority and destination decision documented and appropriate to clinical impression.	Excellent Appropriate transport priority and destination decision documented with justification and explanation.
Summary of findings
Disposition

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