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iRubric: H&P - History Documentation Rubric

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H&P - History Documentation Rubric H&P - History Documentation Rubric Rubric Code: HX63W99 By mtucker01 Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: Graduate

History Documentation Rubric
	Exceeds Expectations 5 pts	Meets Expectations 4 pts	Needs Improvement 3 pts	Unacceptable 2 pts	Did Not Attempt 0 pts
Organization/Clear Communication	Exceeds Expectations Content is clear and well organized in a logical sequence; follows acceptable format	Meets Expectations Content is mostly clear and generally organized in logical sequence; follows acceptable format	Needs Improvement Content is somewhat confusing and disorganized with errors in format	Unacceptable Content is confusing and disorganized with multiple errors in format	Did Not Attempt
Thoroughness of documented history	Exceeds Expectations History includes: 1. CC 2. HPI, including all PQRST attributes 3. Meds/ Allergies 4. PMH 5. PSH 6. FH 7. SH 8. ROS, including at least 10 body systems	Meets Expectations History includes all 8 of the items listed, but omits 1-2 items within a section (ie, misses one body system in ROS)	Needs Improvement History includes 6-7 of the items listed OR omits 3-4 items within a section	Unacceptable History includes 1-5 of the items listed OR omits >4 items within a section	Did Not Attempt
Grammar	Exceeds Expectations Virtually free of any errors in spelling and grammar	Meets Expectations Free of significant errors in spelling and grammar. Errors present do not detract from the overall write-up	Needs Improvement Several errors (3-4) in spelling and grammar	Unacceptable Multiple errors (>4) in spelling and grammar	Did Not Attempt
Terminology	Exceeds Expectations Used correct terminology consistently throughout write-up	Meets Expectations Used incorrect terminology 1-2 times throughout write-up	Needs Improvement Used incorrect terminology 3-4 times throughout write-up	Unacceptable Used incorrect terminology >4 times throughout write-up	Did Not Attempt