iRubric: RNSG325 Health History Interview rubric

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RNSG325 Health History Interview

Health History and Physical Assessment

Rubric for writing up a Comprehensive Health History Interview

Rubric Code: WX22633

By aprilw

Draft

Public Rubric

Subject: Nursing

Type: Assignment

Grade Levels: Undergraduate

Comprehensive Health History
	Inadequate Effort 0 pts	Meets minimum standard (N/A)	Very Good (N/A)	Score (N/A)
Part 1-Initial information
	Inadequate Effort 0 pts	Meets minimum standard 2 pts	Very Good 4 pts	Score (N/A)
Identifying Data/chief complaint 4 pts Provides clearly written explanation of client's chief complaint	Inadequate Effort Student provides no identifying information. Fails to provide a focused written statement for reason/feelings about seeking care.	Meets minimum standard Student failed to provide provide 1-2 items of identifying data. Provides a written statement for reason/feelings for and about seeking care.	Very Good Student includes all elements of identifying data. Provides a focused clearly written statement regarding the patient reason/feelings for and about seeking care. Places reason in quotations.	Score
History of Present Health Concern 4 pts Includes comprehensive subjective data and past medical history	Inadequate Effort Documentation is inadequately addresses client's present health condition with gross deficiencies in grammar, spelling and/or formatting(word usage).	Meets minimum standard Documentation addresses most elements of client's present health history with minor grammatical, spelling, or word usage errors.	Very Good Documentation addresses significant present health history using the proper format with no grammatical, spelling, or word usage errors.	Score
Past/ Family Health History 4 pts Includes comprehensive past medical and family health history data	Inadequate Effort Documentation is inadequate with gross deficiencies in grammer, spelling, and/or word usage.	Meets minimum standard Documentation addresses all key elements with minor grammatical errors, spelling, or word usage errors.	Very Good Documentation correctly addresses key element of past and family health history having the proper format with no grammatical, spelling or word usage errors.	Score
Health Patterns/Lifestyle 4 pts Includes comphrehensive health patterns and lifestyle data	Inadequate Effort Documentation is inadequate with gross deficiencies in grammer, spelling, and or word usage.	Meets minimum standard Documentation addresses all key elements with minor grammatical errors, spelling, and/or word usage errors.	Very Good Documentation correctly addresses every key element having the proper format with no grammatical, spelling or word usage errors.	Score
Part II-Review of Systems
	Inadequate 3 pts	Meets minimum standard 6 pts	Very Good 10 pts	Score (N/A)
Part III-Review of Systems 10 pts Assess all systems appropriately using inspection, palpation and auscultation as indicated. Appropriately assess all negative findings.<BR> Document all findings concisely using appropriate terminology.	Inadequate Student provides limited review of systems documentation.	Meets minimum standard Student provides adequate review of systems documentation that covers majority of systems with minimal grammatical, spelling or word usage errors.	Very Good Student provides a comprehensive review of systems documentation that covers all systems with no grammatical, spelling or word usage errors.	Score
Part III-Prevention and Maintenance
	Inadequate 1 pts	Meets minimum standard 2 pts	Very Good 4 pts	Score (N/A)
Part II-Prevention and Maintenance 4 pts Lists client problems and learning needs based on health history and identified needs. Prioritizes list.	Inadequate Student provides 0-1 recommendations with no rationales provided	Meets minimum standard Student provides at least 3 prioritized recommendations for health promotion with rationales provided.	Very Good Student provides a comprehensive list of prioritized recommendations for health promotion substantiated with referenced rationales.	Score

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