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iRubric: History Appropriate (DRAFT 2) rubric
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History Appropriate (DRAFT 2)
Informed Consent Compliant DRAFT -2-
For use in quality review of chiropractic clinical records.
Rubric Code:
L3XAA8
By
JP_NYCC
Ready to use
Public Rubric
Subject:
Medical
Type:
(Other)
Grade Levels:
(none)
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DC File Review
History Appropriate
Very poor
Red
0 pts
Unacceptable
Red
1 pts
Acceptable
Yellow
2 pts
Good
Green
3 pts
Exceptional
Blue
4 pts
1. Chief Complaint(s)
Very poor
Core components absent.
Unacceptable
Lacks significant required information
Acceptable
All significant data recorded but with little detail
Good
Required elements recorded in reasonable detail
Exceptional
All components thoroughly recorded with exceptional detail
2. Medical, Social, Family History
Very poor
Relevant components not recorded.
Unacceptable
Relevant components addressed but to insufficient degree
Acceptable
All relevant components recorded adequately but with minimal detail
Good
Relevant issues recorded with good detail
Exceptional
All relevant components thoroughly recorded with exceptional detail
3. Review of Systems
Very poor
Absent
Unacceptable
Insufficient detail obtained regarding relevant systems
Acceptable
Adequate investigation of relevant systems but with minimal detail
Good
Reasonably detailed recording of relevant systems
Exceptional
All relevant systems covered with exceptional detail
Keywords:
file, chart, quality, review
Subjects:
Medical
Types:
(Other)
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