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iRubric: Progress Note rubric

iRubric: Progress Note rubric

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Progress Note

  Derived from rubric: Progress Note (DRAFT 2)
built by lmyronuk

Rubric Code: UX8C5CX
For use in quality review of psychiatric records.
ready Ready to use    public Public Rubric

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Keywords: file, chart, quality, review, psychiatry
Categories: Subjects: Medical  
Types: (Other)  
Grade Levels: Graduate, Post Graduate

Powered by iRubric Outpatient Chart Review
Progress Note
  Unacceptable
0 pts Red
Needs improvement
1 pts Red
Acceptable
2 pts Yellow
Good
3 pts Green
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.



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