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iRubric: Physician Assistant Student Inpatient Admission Rubric

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Physician Assistant Student Inpatient Admission Rubric Physician Assistant Student Inpatient Admission Rubric This rubric is designed for the assessment of Physician Assistant Students (PA-S) in developing written inpatient admission notes. This rubric will be applied to papers written for the following clinical rotations: Family Practice, General Surgery, Internal Medicine, Orthopedics, Pediatrics, and Psychiatry. Rubric Code: X4AACC By dsolimini Ready to use Public Rubric Subject: Medical Type: Writing Grade Levels: (none)

I. History I
	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 7.5 pts	Exceptional 15 pts
Chief Complaint (CC) and HPI 15 pts	Unacceptable Chief Complaint and History of Present Illness is scant. The majority of vital information to the chief complaint is missing. Remediation Required	Marginally Acceptable Chief Complaint and History of Present Illness is age and gender appropriate, however is missing some vital information relevant to the chief complaint.	Satisfactory Chief Complaint and History of Present Illness is age and gender appropriate. Some non-vital information relevant to chief complaint is missing. PQRST or OLDCARTS is not adhered to.	Exceptional Chief Complaint and History of Present Illness is complete and age and gender appropriate. It is written in a logical format utilzing PQRST or OLDCARTS.
Complete Review of Systems (ROS) 15 pts	Unacceptable Complete Review of Systems is missing. Remediation Required	Marginally Acceptable Three components of a complete Review of Systems is missing or poorly addressed: General; Skin; HEENT; Respiratory; Cardiac; GI; GU; GYN; Musculoskeletal; Vascular; Neurological; Psychiatric; Endocrine; Hematologic.	Satisfactory Two components of a complete Review of Systems is missing or vaguely addressed. General; Skin; HEENT; Respiratory; Cardiac; GI; GU; GYN; Musculoskeletal; Vascular; Neurological; Psychiatric; Endocrine; Hematologic.	Exceptional A complete Review of Systems is present: General; Skin; HEENT; Respiratory; Cardiac; GI; GU; GYN; Musculoskeletal; Vascular; Neurological; Psychiatric; Endocrine; Hematologic.
II. History II
	Unacceptable 0 pts	Marginally Acceptable 5 pts	Satisfactory 7.5 pts	Exceptional 10 pts
Past Medical History I (PMH) 10 pts	Unacceptable Complete Past Medical History is missing. Remediation Required	Marginally Acceptable Past Medical History is incomplete. There are key components missing from: Childhood illnesses; Adult medical illnesses; Surgeries, OB/GYN; Psychaitric illnesses. The year of diagnosis and treatment is included if known.	Satisfactory Past Medical History complete however there are missing key components from: Childhood illnesses; Adult medical illnesses; Surgeries, OB/GYN; Psychaitric illnesses. The year of diagnosis and treatment is included if known.	Exceptional A complete Past Medical History is present and contains: Childhood illnesses; Adult medical illnesses; Surgeries, OB/GYN; Psychaitric illnesses. The year of diagnosis and treatment is included if known.
Past Medical History II 10 pts Current Medications Allergies Social History Family History	Unacceptable Complete Past Medical History is missing. Remediation Required	Marginally Acceptable Two components of the complete past medical history are missing: Current medications, allergies, social history, and family history.	Satisfactory One component of the complete past medical history is missing: Current medications, allergies, social history, and family history.	Exceptional A complete history is present regarding current medications, allergies, social history, and family history.
III. Physical Examination
	Unacceptable 0 pts	Marginally Acceptable 7.5 pts	Satisfactory 15 pts	Exceptional 20 pts
Physical Examination 20 pts	Unacceptable The physical examination is missing or grossly incomplete. Remediation Required	Marginally Acceptable Four components of the physical examination are missing: Vital Signs General Assessment Skin, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurologic and Psychiatric examiantion.	Satisfactory Two components of the physical examination are missing: Vital Signs General Assessment Skin, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurologic and Psychiatric examiantion.	Exceptional All components of the physical examination are present: Vital Signs General Assessment Skin, HEENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Neurologic and Psychiatric examiantion.
IV. Labs/Diagnostics/Problem List
	Unacceptable 0 pts	Marginally Acceptable 1.5 pts	Satisfactory 3.5 pts	Exceptional 5 pts
Labs/Diagnostic Tests 5 pts	Unacceptable There are no mention of laboratory testing or diagnostic imaging. Remediation Required.	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).
Problem List 5 pts	Unacceptable No problem list is generated. Remediation Required.	Marginally Acceptable The chief problem is documented however other medical problems associated with the admission are not recorded.	Satisfactory The chief problem is documented. One to several of the other medical problems associated with the admission are missing.	Exceptional All associated medical problems associated with the hospital admission are documented.
V. Assement and Plan
	Unacceptable 0 pts	Marginally Acceptable 7.5 pts	Satisfactory 15 pts	Exceptional 20 pts
Assessment and Plan 20 pts	Unacceptable The diagnosis(s), assessments, or treatment plan is not documented. Remediation Required.	Marginally Acceptable The assessment lists the chief complaint but is missing other problems. The treatment plan is incomplete for the complaints presented.	Satisfactory The assessment lists the chief complaint but one or more problems is missing. The treatment plan is complete for the complaints presented.	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.

Keywords:

Physician Assistant

Subjects:

Medical

Types:

Writing

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