iRubric: Student nurse narrative nursing note rubric

Subjective assessment of health status is fully developed and linked to the reason for presentation with relevant information
Note specific and detailed
AMAZING WORK!

Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.
GREAT JOB!

Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes some irrelevant information.
GOOD JOB!

Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem.
There was Irrelevant information is the main theme for the assessment.
GOOD TRY!

Documentation is clear and well organized.
Appropriate medical terminology is used.
Format follows a standard, clean

Documentation meets criteria for "exceptional" but there is occasional repetition of working or phrases.
Some documentation errors.

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence.
Difficult to read documentation

Documentation does not meet expectations for this level as evidenced by either of the following:
lay terminology, illogical sequencing, missing essential elements.
Plagiarism noted from other health care provider notes.

Documentation is clear and well organized.
Appropriate medical terminology is used.
Repetitious words, phrases, and other distracting information are omitted.
Flow is logical from head to toe

Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format for focused head to toe assessment and safety documentation but the reader is able to determine findings with minimal difficulty.

Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format from logical sequence for focused head to toe note and safety but the reader is able to determine findings with difficulty.

Documentation does not meet expectations for this level as evidenced by either of the following: does not clearly show a head to toe assessment, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Plagiarism noted from other health care provider notes.