iRubric: EMS Chart review rubric

Not completely provided.

Information provided, however not accurate.

Needed information provided, accurate, with no further information provided.

Needed information provided, accurate, and documented in narrative.

Needed information provided, accurate, documented in narrative, with additional pertinent specifics documented.

None documented or only one set of vitals documented from transports without a documented explanation.

2 sets of vitals, including blood pressures, documented with no interpretation noted in narrative.

Appropriate sets of vitals documented based on patient acuity with abnormalities discussed in narrative.

Appropriate sets of vitals documented based on patient acuity with interpretation provided in narrative. Additional system specific vitals documented (EtCO2, temperature, BGL, etc.).

Appropriate sets of vitals documented based on patient acuity with interpretation provided in narrative. Additional system specific vitals documented and interpreted (EtCO2, temperature, BGL, etc.).

Focused assessments documented poorly, leaving out key pertinent positives and negatives.

Focused assessments documented, but missing some pertinent information such as pertinent negatives. Assessments documented in both assessments tab and narrative.

Focused assessments documented with reassessment documented in narrative, however not in assessments tab. Pertinent positives documented, with little to no pertinent negatives documented.

Focused assessments documented with reassessment documented in both assessments tab and in the narrative. Pertinent positives and negatives documented. Findings support treatments and provider impressions.

Focused assessments documented with pertinent positives and negatives. Also documents reassessment in both assessments tab and narrative. Assessment findings clearly support indications for treatment and provider impressions with interpretation of findings elaborated on in narrative.

Discusses the events of the incident without elaborating on patient interview, assessment findings, or treatments.

Discusses the events of the incident without discussing patient assessment findings or interview.

Provides clear picture of the incident and highlights pertinent assessment findings. Documents treatments with no elaboration of response to treatment.

Provides clear picture of the incident. Elaborates on assessment findings and patient interview. Documents treatments and their indications, response to treatment included in PCR.

Provides clear picture of the entirety of the incident. Elaborates on assessment findings and patient interview. Describes patient response to treatments. Notates any abnormalities with the incident.