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iRubric: EMS Chart review rubric
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EMS Chart review
EMS Chart review
Patient care report QI review
Rubric Code:
B2492BA
By
Maupinshannon
Ready to use
Public Rubric
Subject:
Medical
Type:
Assessment
Grade Levels:
Graduate
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Desktop Mode
Mobile Mode
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
Subjects:
Medical
Types:
Exam
Assessment
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