iRubric: MDCA 1372 EMR Charting Rubric

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MDCA 1372 EMR Charting Rubric EMS Chart review EMR Charting Office Visit Rubric Code: XX98226 By cyndee_lundgren Ready to use Public Rubric Subject: Medical Type: Exam Grade Levels: 9-12, Undergraduate

EMR Charting
	Poor 1 pts	Fair 2 pts	Good 3 pts	Excellent 4 pts
Patient Demographics 4 pts Name DOB Address	Poor No items reviewed with patient	Fair Only one item reviewed with patient.	Good Only two items reviewed with patient.	Excellent All items reviewed with patient and Updated appropriately in record.
Allergies 4 pts Review of patient allergies	Poor Important information is missing	Fair Some information is missing	Good Information is complete	Excellent Information is complete and well organized.
Complaint 4 pts CC PI	Poor Documented poorly	Fair Documented without explaination	Good Documented and explained	Excellent Documented and well- described with onset, time, and adequate descriptors
History 4 pts Past Medical History Family Medical History Social History	Poor Documented poorly	Fair Documented, but missing information	Good Documented and explained	Excellent Documented and well described with PMH, meds, allergies
Prescription 4 pts Update and Review of patient medications	Poor None documented	Fair Inappropriately documented	Good Appropriately documented	Excellent Appropriately documented & reviewed with patient