iRubric: Student nurse narrative nursing note rubric

» rubrics » iRubric: Student nurse narrative nursing note rubric »

edit print share Copy to my rubrics Bookmark test run assess... delete Do more...

Student nurse narrative nursing note

Rubric designed to evaluate the end of clinical/shift note completed by level one nursing students

Rubric Code: F2237A6

By ingridchen

Ready to use

Public Rubric

Subject: Nursing

Type: Writing

Grade Levels: Undergraduate

Nurse Note Grading Rubric
	Unsatisfactory 5 pts	Below Average 10 pts	Average 16 pts	Above Average 20 pts
Subjective Data Data is fully explained	Unsatisfactory 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	Below Average Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.	Average Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.	Above Average 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
Objective Data Data is fully explained	Unsatisfactory Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/or inappropriate for the presenting problem.	Below Average Two or more elements needed for adequate evaluation of a patient's problem is missing from the subjective and/or objective assessment.	Average Objective assessment is missing an element needed for adequate evaluation of the patient's problem. Includes irrelevant information in assessment of head to toe evaluation	Above Average Objective assessment of health status is fully developed Physical exam includes vital signs, height and weight and any relevant data related to full head to toe assessment of patient
Head to Toe Assessment Abnormal assessment findings identified and documented in narrative SOAP format.	Unsatisfactory Document mostly complete in identifying abnormal findings. Missing 5 or more pertinent abnormal assessment areas.	Below Average Document mostly complete in identifying abnormal findings. Missing 3-4 pertinent abnormal assessment areas.	Average Document incomplete/or erroneous. Missing 1-2 pertinent abnormal assessment findings.	Above Average Documentation is appropriate and complete. All abnormal findings identified and narrative written to explain variation from norms.
Data clear and well organized Documented in SOAP format.	Unsatisfactory Documentation does not meet expectations for this level as evidenced by either of the following: lay terminology, illogical sequencing, missing essential elements. Plagiarism noted from other health care provider notes.	Below Average Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format from logical sequence for head to toe documentation but the reader is able to determine findings with difficulty.	Average Documentation meets criteria for "exceptional" but there is occasional repetiton of workding or phrases. Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format for head to toe documentation but the reader is able to determine findings with minimal difficulty.	Above Average Documentation is clear and well organized. Appropriate medical terminology is used. Repetitious words or phrases are not utilized. Format follows a standard. Narratives for head to toe and follow up notes have a logical flow.
Follow-Up Documentation Last documentation of shit contains appropriate hand-off note.	Unsatisfactory 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.	Below Average 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.	Average 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.	Above Average 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

Subjects:

Types:

Discuss this rubric