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iRubric: Documentation Metadata rubric

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Documentation Metadata For use in quality review of psychiatric records. Rubric Code: XX9XW67 By lmyronuk Ready to use Public Rubric Subject: Medical Type: (Other) Grade Levels: Graduate, Post Graduate

Documentation Metadata Process measures unrelated to document content.
	Unacceptable Red 0 pts	Needs improvement Yellow 1 pts	Good Green 3 pts
Timeliness Was the documentation completed at the time of service?	Unacceptable Greater than two weeks from time of service, or not completed.	Needs improvement Greater than 48h from time of service but within two weeks.	Good Within 48h from time of service.
Distribution Were appropriate service providers copied in?	Unacceptable Most-responsible or primary care provider (MRP, PCP) not copied; wrong PCP identified; no cc recipients specified.	Needs improvement Most-responsible or primary care provider (MRP, PCP) copied, but other service providers (specialists, care facility, etc.) not copied.	Good All appropriate care providers included in copy distribution.
Proofreading Was the documentation posted and distributed with uncorrected errors.	Unacceptable Document posted to chart and distributed according to HIM policy without having been proofread, corrected, and signed by author.	Needs improvement Document signed by author and distributed containing uncorrected errors.	Good Document signed with review and correction of errors (could be in form of addendum to document).
Filing Is the document residing in the correct location within the patient's health record?	Unacceptable Document is in the wrong section of paper chart or incorrect document type in EHR.	Needs improvement Correct document location, but document not titled or titled inappropriately (e.g., "Free text note")	Good Document in correct location within patient record with suitable descriptive title.