iRubric: Progress Note rubric

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Progress Note Progress Note (DRAFT 2) For use in quality review of psychiatric records. Rubric Code: UX8C5CX By lmyronuk Ready to use Public Rubric Subject: Medical Type: (Other) Grade Levels: Graduate, Post Graduate

Outpatient Chart Review Progress Note
	Unacceptable Red 0 pts	Needs improvement Red 1 pts	Acceptable Yellow 2 pts	Good Green 3 pts
1. Subjective	Unacceptable Absent	Needs improvement Recorded for all visits but incomplete. Some required elements missing or difficult to decipher.	Acceptable All required elements recorded for all visits. Detail is adequate but minimal.	Good Notes are thorough and well written. Easy to decipher.
2. Objective	Unacceptable Absent	Needs improvement Recorded for all visits but incomplete. Some required elements missing or difficult to decipher.	Acceptable All required elements recorded for all visits. Detail is adequate but minimal.	Good Notes are thorough and well written. Easy to decipher.
3. Assessment	Unacceptable Absent	Needs improvement Recorded for all visits but incomplete, vague or non-specific.	Acceptable Recorded for all visits. Detail is adequate but minimal.	Good Recorded in detail for all visits, includes revision to DSM codes where appropriate.
4. Plan	Unacceptable Absent. Management plan modifications not made when indicated.	Needs improvement Plan modifications made, but not appropriately driven by patient response/outcome measurement.	Acceptable Appropriately, timely modifications made in accordance with patient response/outcome measurement.	Good Evidence of constant attention to plan modification as indicated for optimal response. Evidence of appropriate transition from passive to active care.