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iRubric: Clinical File Review rubric
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Clinical File Review
For use in quality review of chiropractic clinical records.
Rubric Code:
A3X65W
By
dodiorne
Ready to use
Private Rubric
Subject:
Medical
Type:
(Other)
Grade Levels:
Graduate
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Mobile Mode
DC File Review
Very poor
Red
0 pts
Unacceptable
Red
1 pts
Acceptable
Yellow
2 pts
Good
Green
3 pts
Exceptional
Blue
4 pts
1. Informed consent
Very poor
Non-compliant
Unacceptable
This rating not available for this item.
Acceptable
This rating not available for this item.
Good
Compliant
Exceptional
This rating not available for this item.
2. Privacy Practice
Very poor
Notification not documented
Unacceptable
This rating not available for this item.
Acceptable
This rating not available for this item.
Good
Notification documented
Exceptional
This rating not available for this item.
3. History
Very poor
Does not address chief complaint.
Unacceptable
Lacks significant required data.
Acceptable
Sufficient to understand chief complaint but not comprehensive.
Good
History of chief complaint very well done. All aspects of history meet expectations.
Exceptional
Excellent history in all respects. Exceeds expectations.
4. Clinical Exam
Very poor
Does not demonstrate an understanding of the patient's complaint or history.
Unacceptable
Exam insufficient for diagnosis and/or management.
Acceptable
Sufficient for diagnosis and management of the chief complaint.
Good
Comprehensive examination meets expectations in all respects.
Exceptional
Excellent examination. Exceeds expectations.
5. Advanced Testing
Diagnostic imaging and other advanced testing.
Very poor
Indicated testing not ordered or testing ordered was inappropriate.
Unacceptable
Testing was ordered, but objectives could have been accomplished in a manner more accurate, less invasive, less expensive, quicker, or more convenient.
Acceptable
Testing adequate for diagnosis and management, but better choices could have provide better quality data.
Good
Testing was appropriate in light of DDx and there is clear evidence that best use was made of all information gained.
Exceptional
Testing was optimal in all respects
6. Diagnosis
Very poor
Diagnosis inconsistent with findings and/or problem list is not current.
Unacceptable
Diagnosis is supported by findings, but does not account for all available data.
Acceptable
Diagnosis is consistent with findings and provides an adequate basis for management.
Good
Diagnosis accounts for all significant findings.
Exceptional
All aspects of the diagnosis are completely consistent with available data and are expressed to the highest level of understanding.
7. Tx Plan
Very poor
Plan is missing or inconsistent with diagnosis.
Unacceptable
Plan is incomplete and/or unlikely to achieve desired outcomes.
Acceptable
Plan is appropriate with regard to the chief complaint but does not address co-morbidity.
Good
Plan appropriately addresses all diagnosed conditions.
Exceptional
Plan appropriately addresses all diagnosed conditions and seeks to optimize patient's well-being.
8. Self-care
Very poor
No self-care recommended.
Unacceptable
Recommended self-care is unlikely to be effective.
Acceptable
Self-care recommended is likely to be effective with regard to the chief complaint.
Good
Self-care recommended is likely to be effective with regard to all aspects of the patient's condition.
Exceptional
Self-care recommended is likely to be effective with regard to all aspects of the patient's condition and there is evidence of appropriate follow-up and adjustment as indicated.
9. Management Goals
Very poor
Goals missing or inconsistent with diagnosis.
Unacceptable
Goals appropriate to diagnosis, but unrealistic with regard to degree or time.
Acceptable
Goals are appropriate to diagnosis and are realistic.
Good
Goals are appropriate to diagnosis and are realistic. There is evidence of patient involvement in goal-setting.
Exceptional
There is evidence that discussion of progress toward goals is a consistent aspect of doctor/ patient communication.
10. Outcome Measures
Very poor
Missing or inappropriate.
Unacceptable
Difficult to measure accurately. Do not fully indicate level of progress. May be unreliable.
Acceptable
Adequate indicators of progress toward goals related to chief complaint.
Good
Good indicators of progress toward all diagnosed conditions are included.
Exceptional
Indicators of progress toward optimum well-being are included.
11. Plan Modification
Very poor
Management plan never modified or modification is inconsistent with or unsupported by available data.
Unacceptable
Modifications were made when indicated but are unlikely to improve patient response to care.
Acceptable
Appropriate modifications made in a timely manner and are likely to improve response.
Good
Evidence of constant attention to modification of treatment plan as indicated for optimum response.
Exceptional
Modifications of treatment plan show evidence of patient involvement and buy-in.
12. Management Benefit
Very poor
Undocumented
Unacceptable
Some documentation, but not consistently expressed in terms of predetermined goals and outcome measures.
Acceptable
Documentation of benefit with regard to chief complaint considers predetermined goals and outcome measures.
Good
Comprehensive documentation of benefit regarding all diagnosed conditions considers predetermined goals and outcome measures.
Exceptional
Includes documentation of benefit with regard to progress toward optimum well-being.
13. Progress Notes
Very poor
Missing or not in required format.
Unacceptable
Notes recorded for all visits but are incomplete. Some required elements missing.
Acceptable
All required elements present for all visits. Detail is adequate for effective case management.
Good
Notes are comprehensive and exceptionally well written. Few or no grammatical errors.
Exceptional
The chart is a professional liability defense attorney's dream!
14. Legibility
Very poor
Unreadable
Unacceptable
Mostly readable with difficulty. Some words can not be made out.
Acceptable
Completely readable with some difficulty.
Good
Easily read.
Exceptional
Electronic health record.
Keywords:
file, chart, quality, review
Subjects:
Medical
Types:
(Other)
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