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iRubric: CMA Midterm Practicuum rubric

iRubric: CMA Midterm Practicuum rubric

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CMA Midterm Practicuum Medical Assisting Assessment How to collect all necessary data in the clinical setting in order to write a complete Patient Assessment. Rubric Code: V249C7W By JeanMD Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: Undergraduate

Assessment Skill
	Excellent 5 pts	Good 4 pts	Fair 3 pts	Poor 2 pts
Infection Control Standard Precautions in patient care. Handwash or Alcohol hand prep	Excellent Check all common surfaces upon arrival, perform 2 minute hand wash before seeing 1st patient-, use of proper PPE in potential biohazards, disinfect all surfaces and proper disposal of all contaminated materials and wash hands 1minute after patient exam	Good Perform 2minute hand wash before 1st patient, patients, use of gloves in potential biohazards, clean all surfaces and dispose of contaminated materials, wash hands 1minute after patient exam	Fair wash hands <2minutes prior to 1st patient, clear all surfaces of contaminated materials, place contaminated material in waste can	Poor Fails to wash hands <2minutes prior to 1st patient, clear all surfaces of contaminated materials, place contaminated material in waste can
Greeting patient	Excellent Introduces himself/herself. Greets patient and verifies patient identity.	Good Introduces himself/herself. Greets patient but does not verify patient identify	Fair Does not introduce himself/herself. Greets patient and verifies patient identity.	Poor Does not introduce himself/herself. Does not greet patient nor verify patient identity.
Vital Signs Explains procedure to patient ; Correct technique for measurement. Correct units when documenting.	Excellent Explains procedure. Obtains blood pressure, pulse, respirations, and temperature correctly.	Good Explains procedure. Only obtains three of four vital signs correctly.	Fair Explains procedure. Only obtains two of four vital signs correctly.	Poor Does not explain procedure. Only obtains one of four vital signs correctly.
Present Illness Assessment Chief Complaint	Excellent Obtains detailed illness history, including date/time of onset, provocation of illness/injury (what caused it), detailed description of signs/symptoms/pain, rating of pain on the 0-10 scale, quality of pain (sharp, stabbing, etc.), radiation of pain (does it travel and if so where), and relief measures/medication tried and their effectiveness.	Good Obtains illness assessment but misses one of the critical areas described.	Fair Obtains illness assessment but misses two of the critical areas described.	Poor Obtains illness assessment but misses three or more of the critical areas described.
Rationale Articulation to the patient regarding the selection of vital signs and other clinical skills performed.	Excellent Verbalizes relevant information relating to the skill being performed. Answers instructor's questions regarding the skill and its importance plus the impact to the patient without difficulty.	Good Able to verbalize relevant information relating to the designated skill that is being performed. Able to answer more than four questions regarding the skill and its importance regarding the skill and its importance plus the impact to the patient	Fair Basic Limited ability to verbalize relevant information relating to the designated skill that is being performed. Able to answer less than three questions regarding the skill and its importance plus the impact to the patient.	Poor Below Basic Fails to verbalize relevant information relating to the skill being performed. Unable to answer instructor's questions regarding the skill and its importance and/or impact to the patient.
Physician Orders Any additional tests - Visual Acuity, blood glucose screen, wound swab, eye/ear procedures etc- as specified on assessment cards	Excellent Obtains any specimen necessary and performs in office testing.	Good Obtains any specimen necessary but performs only part of the necessary testing.	Fair Obtains any specimen necessary but does not perform correct testing.	Poor Does not obtain nor test any specimen.
Injections Demonstrate each of the steps required in administering injections	Excellent calculated/withdrew prescribed dosage accurately. Able to site the 7 rights for drug administration. Followed all safety procedures when handling equipment. Inserted needle at the correct angle for each of the injections demonstrated. Documents injection administration.	Good calculated/withdrew prescribed dosage accurately. Able to site the 7 rights for drug administration. Followed all safety procedures when handling equipment. Inserted needle at the correct angle for each of the injections demonstrated.	Fair calculated/withdrew prescribed dosage accurately. Able to site the 7 rights for drug administration. Followed all safety procedures when handling equipment.	Poor Failed to accurately calculate prescribed dosage/ withdraw correct dose of Medication. Unable to site the 7 rights for drug administration. Did not follow safety procedures when handling equipment.
Communication 1) Tone, clarity, and use of terminology 2) Nonverbal communication is respectful and appropriate for environment 3) Uses correct terminology in oral communication	Excellent Demonstrates ALL of the communication skills in a logical manner consistently without difficulty	Good Demonstrates ALL/MOST of the communication skills in a logical manner throughout the scenario MOST of the time.	Fair Able to demonstrate some of the communication skills, throughout the scenario. Needs improvement.	Poor Fails to demonstrate most of the communication skills
Documentation	Excellent Review demographic sheets for completeness and make needed corrections, complete history form accurately(check for allergies/medications, sign and date Hx form, use SOAP format for return visits,sign and date	Good Review demographic sheets and place in chart, complete Hx form and place in chart sign and date, make note of all follow up visits(not with SOAP)	Fair Place demographic sheets in chart, complete Hx form, make note of return visits (lack of signatures/dates)	Poor Incomplete demographic sheets Incomplete Assessment Forms Missing date,time of service Missing signature procedures not documented

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Medical Assisting

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