iRubric: Student nurse narrative nursing note rubric

Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information is the main theme for the assessment

Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.

Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.

Subjective assessment of health status is fully developed and linked to the reason for presentation without including irrelevant information.
Assessment is fully developed and includes location, duration, timing, character, severity provocative/palliative factors and/or other features appropriate for the reason for presentation.
Note specific and detailed

Document mostly complete in identifying abnormal findings. Missing 5 or more pertinent abnormal assessment areas.

Document mostly complete in identifying abnormal findings. Missing 3-4 pertinent abnormal assessment areas.

Document incomplete/or erroneous. Missing 1-2 pertinent abnormal assessment findings.

Documentation is appropriate and complete. All abnormal findings identified and narrative written to explain variation from norms.

Incorrectly or fails to apply evidence-based guidelines to assesment, DX, plan, patient education, or follow-up. does not clearly show follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. Use of lay terminology, illogical sequencing, missing essential elements, and/or 5 or more spelling or grammatical errors.

Documentation meets criteria for clarity but needs to be better organized. Occasionally strays from standard format from logical sequence for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. The reader is able to determine findings with difficulty. Use of lay terminology, illogical sequencing, missing essential elements, and/or more than 3-4 spelling or grammatical errors.

Documentation meets criteria for "exceptional" but there is occasional redundant/distracting info. Follow up plan is appropriate and meets above criteria but is "generic" occasionally strays from standard format for follow up to pain or prn meds, urgent situations, or abnormalities in head to toe assessment. Includes only 1-2 minor errors in the application or omission of evidence-based guidelines to assessment,DX,plan, patient education, or follow-up.

Documentation is clear & well organized.
Appropriate medical terminology & phrases. Redundant words & other distracting info. are omitted. Follow up to pain, prn meds, urgent situations, or abnormalities in head to toe assessment follow a standard & has logical flow.
Plan is appropriate for the DX & accurately addresses the problem identified for eval/Follow up