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Health History Write-Up 
Health History Write-Up
Rubric Code: W9W8W8
By JKLandrum
Ready to use
Public Rubric
Subject: Nursing  
Type: Assignment  
Grade Levels: Undergraduate

Powered by iRubric Criteria
100 %
  Novice

(N/A)

Apprentice

60 pts

Proficient

80 pts

Distinguished

100 pts

Identifying Data
10 pts

1. Demographic/ Biographical Data
2. Source of Data
3. Reliability of Source
Novice

No data
Apprentice

Some demographic data included, source of data or the reliability of the data source not included.
Proficient

Most demographic data included but missing either the source of the data or the reliability of the data source.
Distinguished

Demographic data is complete, source of data and reliability of data source is included.
Chief Complaint
5 pts

1. Reason for seeking care
2. Time Frame
Novice

No data
Apprentice

The main symptom, sign or complaint is not clear or is written as a diagnosis, lacks time frame or is not written using the words of the source of the data.
Proficient

Chief complaint is clear and includes time frame but is not written using the words of the source of the data.
Distinguished

Chief complaint is clear, includes time frame and uses the words of the source of the data.
HPI
20 pts

O
L
D
C
A
R
T
Novice

No data
Apprentice

Addresses 4 of the 8 topics of the history of present illness or current health status and/or data is inconsistent or incomplete.
Proficient

Addresses 6 of the 8 topics of the history of present illness or current health status, data is consistent and complete.
Distinguished

Addresses all topics of the history of present illness or current health status, data is consistent and complete.
PMH
20 pts

1. Childhood Illnesses
2. Adult Illnesses
a. Medical
b. Surgical
c. OB/GYN/Sexual Health
d. Psychiatric
3. Immunizations and dates
4. Screening tests, dates, places and results
5. Allergies
6. Current Meds
Novice

No data
Apprentice

Addresses 2 of 4 topics of the past history, data is inconsistent or incomplete.
Proficient

Addresses 3 of 4 topics of the past history, data is consistent and complete.
Distinguished

Addresses all topics of the past history, data is consistent and complete.
Family History
10 pts

1. Past history of maternal and paternal grandparents, parents, siblings, and children (with current age or age of death and reason for death).
2. Presence of serious disease and/or symptoms.
Novice

No data
Apprentice

Address 1 of 3 generations, missing data and/or no evaluation of data.
Proficient

Addresses 2 of 3 generations, no missing data, evaluation of data.
Distinguished

Addresses 3 of 3 generations, no missing data, evaluation of data.
Social History (Functional Assessme
20 pts

1. Self-Concept
2. Activity
3. Sleep
4. Nutrition/Elim
5. Relationships
6. Coping/Stress
7. Personal Habits
8. Environment
9. Violence
10. Occupational
11. Perception
Novice

No data
Apprentice

Addresses 2 of 4 topics of the personal/social history, data is inconsistent or incomplete.
Proficient

Addresses 3 of 4 topics of the personal/social history, data is consistent and complete.
Distinguished

Addresses all topics of the personal/social history, data is consistent and complete.
Review of Systems
30 pts

1. Records the presence or absence of specific diseases or symptoms common to each body system.
2. Organized from head to toe.
3. Does not repeat questions asked in prior sections.
Novice

No data
Apprentice

Addresses 10 of the 16 body systems, data is inconsistent, previously documented and/or incomplete.
Proficient

Addresses 13 of the 16 body systems, data is consistent, complete and not previously documented.
Distinguished

Addresses all of the body systems, data is consistent, complete and not previously documented.
Organization and Presentation
10 pts

Novice

Poorly organized. Terminology inaccurate/imprecise. Needs more practice in written presentation of data for a history, frequent objective information reported. No title page included.
Apprentice

Fair organization. Presentation of data somewhat disorganized. Terminology sometimes inaccurate or imprecise. Presents some data that is inconsequential and/or redundant, occasional objective information. Title page included but not correctly formatted in APA style.
Proficient

Satisfactory organization. Presentation is basically organized & pertinent. Use of terminology generally adequate though at times imprecise. Little, if any redundancy. Rare objective findings, Title page included, almost correctly formatted in APA style.
Distinguished

Good organization. Data presented in a logical, organized manner. Clear, concise, pertinent information without redundancy. Use of terminology accurate & precise. No objective findings. Title page included, correctly formatted in APA style..




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