iRubric: Narrative Nursing Notes Rubric

Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective 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 explicated
and targeted toward the reason for presentation without the inclusion of extraneous 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.<BR>
Note specific and detailed

Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up.

Plan is inadequate to fully address the identified problem.expansive or overwhelming for the client or healthcare system OR
Needs to consider alternative features for optimal outcomes

Plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.

Plan is appropriate for the diagnosis and accurately addresses the problem identified.
Plan is economically sound.
Plan includes plans for evaluation/follow-up care (as appropriate).
Plan is individualized to the patient's age and development, culture, religion, family, environment, education, and/or any other unique concerns uncovered in assessment.