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iRubric: EMS Chart review rubric

iRubric: EMS Chart review rubric

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EMS Chart review 
Patient care report QI review
Rubric Code: Y2473C7
Ready to use
Public Rubric
Subject: Medical  
Type: Assessment  
Grade Levels: Graduate

Powered by iRubric Patient Care Report
  Unacceptable

0 pts

Poor

1 pts

Fair

3 pts

Good

4 pts

Excellent

5 pts

PCR Review Reason:
Legibility/grammar/spelling

Unacceptable

Unable to read
Poor

Difficult to read
Fair

Hand-written with errors
Good

Typed/hand-written with spelling errors or invalid/confusing/unclear abbreviations and easy to read
Excellent

Typed and easy to read, no spelling errors, no confusing or unclear abbreviations
Completeness - tells the story

Unacceptable

Critical information is missing
Poor

Important information is missing
Fair

Some information is missing
Good

Information is complete, may be disorganized
Excellent

Information is complete and well organized, story flows
Chief Complaint/Reason for call

Unacceptable

None Documented
Poor

Documented poorly
Fair

Documented but missing information
Good

Documented and explained
Excellent

Documented and well described, with onset, duration, and adequate descriptors
History

Unacceptable

None documented
Poor

Documented poorly
Fair

Documented but missing some information
Good

Documented and explained
Excellent

Documented and well described with PMH, medications and allergies
Assessment

Unacceptable

None documented
Poor

Documented poorly, leaving out key pertinent positives and negatives
Fair

Documented, but missing some pertinent information.
Good

Documented with all pertinent information.
Excellent

Documented with indications of extensive assessment including differential assessment. Also documents reassessment.
Clinical Impression

Unacceptable

None documented.
Poor

Documented poorly, leaving out key pertinent positives and negatives.
Fair

Documented, but missing some pertinent information.
Good

Documented with all pertinent information.
Excellent

Documented with indications of extensive assessment including differential assessment. Also documents reassessment.
Treatment

Unacceptable

None documented; no specific protocol being identified.
Poor

Documentation indicates poor treatment modalities or treatment is documented poorly. Protocol used not clearly identified. Diagnostic testing (12 leads, fingersticks, capnography) not documented or attached as part of the PCR. Unable to match treatment documented with clinical impression.
Fair

Documented but not followed by effects of treatment. Protocol used identified; diagnostic testing (12 leads, fingerstick, capnography) not complete or mis-interpreted or not attached to the PCR. Treatment documented follows clinical impression.
Good

Appropriately documented treatment. Protocol used identified; diagnostic testing (12 leads, fingerstick, capnography) complete and attached to PCR. Treatment documented follows clinical impression.
Excellent

Documented well, indicating appropriate treatment and describes effects of treatment. Protocol used identified and followed; Diagnostic testing (12 leads, fingersticks, capnography) documented completely, attached to PCR and treatment follows protocol. Treatment follows clinical impression.
Document Response to Treatment

Unacceptable

None documented
Poor

Response to treatment documented poorly or incompletely.
Fair

Response to treatment documented without explanation; omissions of pertinent positives and negatives post treatment.
Good

Response to treatment documented and explained, with appropriate positives and negatives.
Excellent

Documented and well- described with onset, time, and adequate descriptors, pertinent positives and negatives.
DMO; if required or used

Unacceptable

Required but not done
Poor

Required and done, but inadequately - orders denied OR requested (not required), not done adequately and orders denied
Fair

Required and done; documentation inadequate but orders obtained OR requested but not required, documentation inadequate and orders obtained.
Good

Required and done; documentation adequate and orders obtained OR requested but not required, documentation adequate and orders obtained.
Excellent

Required and done; documentation complete and descriptive; and orders obtained OR requested but not required, documentation complete and descriptive; and orders obtained.
Transport decision

Unacceptable

Transport decision: i.e. priority and destination not documented
Poor

Transport priority and/or destination decision inappropriate for clinical impression.
Fair

Transport priority or destination decision not appropriately documented, does not concur with clinical impression.
Good

Appropriate transport priority and destination decision documented and appropriate to clinical impression.
Excellent

Appropriate transport priority and destination decision documented with justification and explanation.
Summary of findings
Disposition




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