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iRubric: Ob & Gyn Rotational Clinical Assessment rubric
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Ob & Gyn Rotational Clinical Assessment
Ob & Gyn Clerkship Clinical Assessment
This rubric is designed for the assessment ofresidents during their Ob & Gyn rotation at RBMC
Rubric Code:
U59665
By
brugpa
Ready to use
Public Rubric
Subject:
Medical
Type:
Assessment
Grade Levels:
Post Graduate
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Mobile Mode
I. History
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
5 pts
Satisfactory
12.5 pts
Exceptional
20 pts
Chief Complaint (CC) and HPI
Not Observed
Unacceptable
Chief Complaint and History of Present Illness is scant. The majority of vital information to the chief complaint is missing.
Marginally Acceptable
Chief Complaint and History of Present Illness is age appropriate, however is missing some vital information relevant to the chief complaint. It is not logically written.
Satisfactory
Chief Complaint and History of Present Illness is age and ob gyn appropriate if applicable. Some non-vital information relevant to chief complaint is missing. It is written in a logical format.
Exceptional
Chief Complaint and History of Present Illness is complete ;age and ob gyn appropriate. It is written in a logical format.
II. History II
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
5 pts
Satisfactory
7.5 pts
Exceptional
10 pts
Past Medical History I (PMH)
Not Observed
Unacceptable
Complete Past Medical History is missing.
Marginally Acceptable
Past Medical History is incomplete. There are key components missing from: Medical illnesses and hospitalizations; Surgeries, OB/GYN;
Satisfactory
Past Medical History complete however there are missing key components from:
Medical illnesses and hospitalizations; Surgeries, OB/GYN;
Exceptional
A complete Past Medical History is present and contains:Medical illnesses and hospitalizations; Surgeries, OB/GYN;
History II
Not Observed
(N/A)
Unacceptable
0 pts
Marginally acceptable
5 pts
Acceptable
7.5 pts
Exceptional
10 pts
Past Medical History II
Not Observed
Unacceptable
Complete Past Medical History is missing.
Marginally acceptable
Two components of the complete past medical history are missing or the components are incomplete: Current medications, allergies, social history.
Acceptable
One component of the complete past medical history is missing or the components are incomplete: Current medications, allergies, social history.
x
Exceptional
A complete history is present regarding current medications, allergies, social history.
III. Physical Examination
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
7.5 pts
Satisfactory
15 pts
Exceptional
20 pts
Physical Examination
Not Observed
Unacceptable
The physical examination is missing or grossly incomplete.
Marginally Acceptable
Four components of the physical examination are missing:
Vital Signs including BMI
General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.
Satisfactory
Two components of the physical examination are missing:
Vital Signs including BMI
General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.
Exceptional
All components of the physical examination are present:
Vital Signs including BMI
General Assessment, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, and Neurologic assessment.
IV. Labs/Diagnostics/Problem List
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
5 pts
Satisfactory
10 pts
Exceptional
15 pts
Labs/Diagnostic Tests
Not Observed
Unacceptable
There are no mention of laboratory testing or diagnostic imaging.
Marginally Acceptable
Some of the appropriate labs and diagnostic studies have been addressed. Abnormal findings are not flagged as high (H) or low (L).
Satisfactory
All appropriate labs and diagnostic studies are recorded.
Abnormal findings are not flagged as high (H) or low (L).
Exceptional
All appropriate labs and diagnostic studies are recorded. All abnormal findings are flagged as high (H) or low (L).
V. Assement and Plan
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
7.5 pts
Satisfactory
15 pts
Exceptional
25 pts
Assessment and Plan
Not Observed
Unacceptable
The diagnosis(s), assessments, or treatment plan is not documented. Does not follow evidence based medicine
Marginally Acceptable
The assessment lists the chief complaint but is missing other problems. The treatment plan is incomplete for the complaints presented. Some follow of evidence based medicine.
Satisfactory
The assessment lists the chief complaint but one or more problems is missing. The treatment plan is complete for the complaints presented and follows evidence based medicine.
Exceptional
The assessment lists ALL of the pertinent problems for the patient, not just the chief complaint. The plan is ordered properly and follows evidence based medicine, is appropriate for the patient and demonstrates a logical progression of knowledge.
VI. Procedural Skills
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Aceptable
5 pts
Satisfactory
7.5 pts
Exceptional
10 pts
Procedural Skills
Not Observed
Unacceptable
Difficulty using proper technique; awkward with equipment or bypasses accepted steps; timing, coordination and/or organization are faulty. Technique places self/patient at risk.
Marginally Aceptable
Some difficulty using proper technique; sometimes fails to organize equipment before procedure; occasional problems with timing or coordination.
Satisfactory
Some difficulty using proper technique; sometimes fails to organize equipment before procedure; occasional problems with timing or coordination.
Exceptional
Timing is precise; procedures performed with ease and dexterity. Able to put patient at ease.
VII. Medical Knowledge
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
5 pts
Satisfactory
7.5 pts
Exceptional
10 pts
Medical Knowledge
Not Observed
Unacceptable
Poor recall of basic science, pathophysiology & clinical information; cannot relate it to cases.
Marginally Acceptable
Has basic knowledge of disease processes & pathologic events; some ability to relate information to clinical material.
Satisfactory
Above average knowledge relevant to assigned patients; able to correlate this knowledge consistently with clinical material.
Exceptional
Superior knowledge with mature application to clinical setting; able to evaluate/apply recent literature.
VIIIDifferential Diagnosis and Prob
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
2.5 pts
Satisfactory
7.5 pts
Exceptional
10 pts
Diff Dx and Problem Solving
Not Observed
Unacceptable
Unable to integrate elements of a clinical knowledge base; has only rudimentary problem-solving ability. Cannot generate problem list or differential diagnosis.
Marginally Acceptable
Somewhat awkward in integrating elements of a clinical knowledge base. Can generate short list of appropriate differential diagnoses for assigned patients.
Satisfactory
Able to synthesize many aspects of the clinical knowledge base into a differential diagnosis and plan that is supported by basic evidence-based standards.
Exceptional
Produces sophisticated differential diagnoses and plans; synthesizes patient's problems according to priority.. Diagnostic reasoning and testing strategies are astute.
IX. Practice based Learning & Imprv
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
5 pts
Satisfactory
10 pts
Exceptional
15 pts
Practice based Learning & Improvmnt
Not Observed
Unacceptable
Little evidence of assigned or supplemental reading. Cannot accept constructive criticism. Fails to share knowledge with others.
Marginally Acceptable
Completes reading and study assignments. Accepts feedback when offered. Takes responsibility for own actions. Will offer information when solicited.
Satisfactory
Does some supplemental as well as assigned reading. Actively solicits and incorporates feedback. Volunteers information with peers.
Exceptional
Self-motivated to expand knowledge; intellectually curious. Seeks advice and consultation when needed. Is self-reflective. Takes active role in sharing information with peers. Contributes to teaching efforts on the service
X INTERPERSONAL AND CO
Not Observed
(N/A)
Unacceptable
0 pts
Marginally Acceptable
5 pts
Satisfactory
10 pts
Exceptional
15 pts
INTERPERSONAL AND CO
Not Observed
Unacceptable
Communicates poorly with patients. Written clinical encounters records are incomplete, poorly organized, or illegible. Student fails to keep appropriate records. Oral presentations are disorganized & poorly integrated.
Marginally Acceptable
Utilizes basic communication strategies. Written clinical encounters records are occasionally incomplete or disorganized. Oral presentations generally organized, but verbose or incomplete.
Satisfactory
Utilizes appropriate communication strategies with patients. Written clinical encounters records cover primary problems in a complete and organized manner. Well-organized, coherent & complete oral presentations.
Exceptional
Communicates effectively with most patients. Written clinical encounters records are prompt, concise, accurate, thorough, relevant; important problems reported & adequately explained. Oral presentations are complete, concise, orderly & polished; intellectually aggressive; clear delineation of all clinical issues.
XI. PROFESSIONALISM
Not Observed
(N/A)
Unacceptable
0 pts
Marginally acceptable
5 pts
Acceptable
12.5 pts
Exceptional
20 pts
Professionalism
Not Observed
Unacceptable
Insensitive to patients and families. Fails to recognize appropriate boundaries with patients. Lacks sensitivity to patient individuality
Marginally acceptable
Sometimes has difficulty establishing rapport with patients and families. Sometimes recognizes importance of patient individuality.
Acceptable
Relates well to most patients and family members. Demonstrates sensitivity and responsiveness to patient individuality.
Exceptional
Demonstrates sensitivity and responsiveness to patient individuality. Consistently demonstrates respect, empathy and compassion for patients and families.
WORK HABITS & PERSONAL ACCOUNTABILI
Not Observed
(N/A)
Unacceptable
0 pts
Marginally acceptable
10 pts
Acceptable
15 pts
Exceptional
20 pts
WORK HABITS & PERSONAL ACCOUNTABILI
Not Observed
Unacceptable
Shirks responsibilities; disorganized. Frequently late. Fails to assume appropriate share of team work. Lacks accountability Fails to recognize or address personal limitations
Marginally acceptable
Assumes expected responsibilities. Demonstrates accountability to patients, peers and team members. Can recognize personal limitations
Acceptable
Independent initiative; well organized. Strong sense of accountability to patients peers and team members. Recognizes and addresses personal limitations
Exceptional
Assumes leadership roles Strong sense of accountability to patients, peers and team members. Recognizes and addresses personal limitations and has the ability to be self reflective
Keywords:
Residents
Subjects:
Medical
Types:
Writing
Assessment
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