iRubric: Clinical Evaluation Papers rubric

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Clinical Evaluation Papers Clinical Evaluation Papers This is the rubric to be used by AU faculty when grading clinical evaluation papers submitted by senior physician assistant students in their clinical year. This rubric will be applied to papers written for the following rotations: Geriatrics/Psychiatry, Internal Medicine, Pediatrics, Surgery, and Women's Health. Rubric Code: Y2B972 By rachelditoro Ready to use Public Rubric Subject: Health Type: Assignment Grade Levels: (none)

I. HPI DIRECTED for G/P, Surg, & WH COMPRESHENSIVE for IM and Peds
	Consider Remediation 0 pts	Unacceptable 6 pts	Marginally Acceptable 7 pts	Satisfactory 8 pts	Very Good 9 pts	Exceptional 10 pts
I A: History 10 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program.	Unacceptable History is scant. The majority of vital information to the chief complaint is missing.	Marginally Acceptable	Satisfactory History is age and gender appropriate and contains pertinent information. However, it is missing some vital points relating to the chief complaint.	Very Good	Exceptional History is complete and age and gender appropriate. It is written in logical format (utilizing OLDCARTS or OPQRST)
I B: History 10 Points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable One or more of the following are missing: PMH, PSH, Medications, Allergies, Social History.	Marginally Acceptable	Satisfactory Pertinent PMH, PSH, Medications, Allergies, and Social History are noted but may not be complete/some pertinent negatives are missing.	Very Good	Exceptional There is complete list of pertinent PMH, PSH, Medications, Allergies, and Social history. Pertinent negatives are listed in all categories.
IC. ROS
	Consider Remediation 0 pts	Unacceptable 3 pts	Marginally Acceptable 3.5 pts	Satisfactory 4 pts	Very Good 4.5 pts	Exceptional 5 pts
IC: ROS 5 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable Review of systems is incomplete and the majority of pertinent positives and negatives are missing from the HPI. (ALL) *A separate ROS is listed but is largely incomplete. (IM/Peds)	Marginally Acceptable	Satisfactory The majority of pertinent positives and negatives are noted in the HPI, but several are missing. (ALL) A separate ROS is noted but is somewhat incomplete. (IM/Peds)	Very Good	Exceptional There is a complete review of systems addressing all systems related to chief complaint noted in the HPI. (ALL) A complete and separate ROS is listed. (IM/Peds)
II. Physical Exam DIRECTED for G/P, Surg, WH COMPREHENSIVE for IM and Peds
	Consider Remediation 0 pts	Unacceptable 12 pts	Marginally Acceptable 14 pts	Satisfactory 16 pts	Very Good 18 pts	Exceptional 20 pts
IIA. Physical Examination 20 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable Appropriate physical examination is incomplete. The information obtained would not be sufficient to support the diagnosis. (EM & FP) The physical examination has not been completed as instructed. (DIRECTED for G/P, Surg, & WH. COMPREHENSIVE for IM and Peds)	Marginally Acceptable	Satisfactory Physical exam is appropriate for the chief complaint but there are pertinent systems or special tests missing. (ALL) Physical examination is appropriate for chief complaint but not all other systems were examined (IM and Peds Only)	Very Good	Exceptional Physical exam has been completed as instructed, is age and gender appropriate, relates to the chief complaint, and pertinent findings in the HPI. All appropriate special tests are noted. (ALL) Physical Examination is appropriate and comprehensive (IM and Peds only)
II B. Lab/Diag
	Consider Remediation 0 pts	Unacceptable 3 pts	Marginally Acceptable 3.5 pts	Satisfactory 4 pts	Very Good 4.5 pts	Exceptional 5 pts
IIB. Labs/Diagnostic Tests 5 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable The majority of the appropriate tests are missing and/or abnormal findings were not flagged as (H) high or (L) low.	Marginally Acceptable	Satisfactory Some of the appropriate labs/diagnostic tests have been ordered. Several may be missing and/or abnormal findings were not flagged as (H) high or (L) low.	Very Good	Exceptional All appropriate labs and diagnostic tests are recorded. Abnormal findings are flagged as (H) high or (L) low
III. A & P
	Consider Remediation 0 pts	Unacceptable 6 pts	Marginally Acceptable 7 pts	Satisfactory 8 pts	Very Good 9 pts	Exceptional 10 pts
III. Assessment and Plan 10 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable The main problem is not listed, the majority of the plan is missing, and/or there is a recommendation that is potentially harmful for the patient.	Marginally Acceptable	Satisfactory The assessment lists the chief complaint/main problem for the patient but one or more problems is missing. The plan is appropriate but not complete or contains recommendations which may not be appropriate for the patient.	Very Good	Exceptional The assessment lists ALL of the pertinent problems for the patient, not just the chief complaint. The plan is ordered properly, follows evidence based medicine, is appropriate for the patient, and demonstrates a logical flow of information.
IV.Clin Synthesis
	Consider Remediation 0 pts	Unacceptable 6 pts	Marginally Acceptable 7 pts	Satisfactory 8 pts	Very Good 9 pts	Exceptional 10 pts
IV. Clin Synthesis IV A. Treatment Plan (10 points)	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable Discussion of actual vs. best treatment as supported by literature is weak and incomplete. There is no clear explanation of whether or not the patient's treatment agrees with literature and there are no additonal recommendations	Marginally Acceptable	Satisfactory There is discussion of actual treatment vs. best treatment as supported by literature but it is incomplete. Student does not point out how he/she may have treated the patient differently/or does not defend current practice.	Very Good	Exceptional There is a complete discussion of the patient's actual treatment vs. best treatment as supported by the cited literature. Student discusses if and how he/she would treat this patient differently based on these findings. *If the literature supports recommended treatment the student defends the current practice
IV. Clin Synthesis IV B. Disposition/Patient Education (10 points)	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable There is little or no discussion of the patient's disposition/follow-up care. There is little or no discussion of support therapies. Patient education is noted but MOST of the major points are missed. OR There is no mention of patient education to be done at a future date.	Marginally Acceptable	Satisfactory There is an incomplete discussion regarding patient disposition/follow-up care. There is an incomplete discussion regarding support therapies. *Patient education is noted but incomplete. OR There is no mention of future patient education.	Very Good	Exceptional There is a complete explanation of patient disposition/follow-up care. There is complete discussion re: recommended support therapies (OT/PT/Speech etc) It should be stated if none are recommended at this time. *Patient education is discussed thoroughly. OR Plans for future patient education is noted.
IV. Clin Synthesis
	Consider Remediation 0 pts	Unacceptable 3 pts	Marginally Acceptable 3.5 pts	Satisfactory 4 pts	Very Good 4.5 pts	Exceptional 5 pts
IV C. Alternative Management 5 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable There is little of no attempt to address alternative plans of treatment and little or no indication that there has been a literaturere review.	Marginally Acceptable	Satisfactory There is an incomplete discussion of alternative plans of treatment or poor reference to the student's literature review.	Very Good	Exceptional There is a complete discussion of alternative plans of treatment including those on the horizon. This is based on the student's literature review.
V. Medication List
	Consider Remediation 0 pts	Unacceptable 3 pts	Marginally Acceptable 3.5 pts	Satisfactory 4 pts	Very Good 4.5 pts	Exceptional 5 pts
V. Medication List 5 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable Most medications are missing Indications are incorrect or the use of this medication may cause harm. Contraindications are incorrect. Critical potential side effects or drug interactions are not addressed.	Marginally Acceptable	Satisfactory List of medications is incomplete Generic and or brand names are not listed Indications are incomplete or not pertinent to this patient. Contraindications are incomplete *Potential side effects are incomplete	Very Good	Exceptional List includes medications that the patient was on prior to the visit, and those given during the visit. Both generic and brand names are listed Indications noted Contraindications noted * Potential Side effects noted
VI. Style
	Consider Remediation 0 pts	Unacceptable 6 pts	Marginally Acceptable 7 pts	Satisfactory 8 pts	Very Good 9 pts	Exceptional 10 pts
VI. Style 10 points	Consider Remediation Faculty may assign "0" points when work in the category is far below what is expected from a graduate-level student in this program	Unacceptable The paper does not relay adequate information on the subject, is disorganized and difficult to follow. The paper has numerous errors in spelling, grammar, punctuation, and pagination. *There is inappropriate use of medical terminology.	Marginally Acceptable	Satisfactory The paper relays information but is slightly disorganized. The content has several mistakes in spelling, grammar, punctuation, and/or pagination. *Medical terminology is used appropriately most of the time	Very Good	Exceptional The paper is well-written in a logical orgainzed manner. The paper has appropriate spelling, grammar, punctuation, and pagination. *There is consistent and appropriate use of medical terminology

Keywords:

Medical

Subjects:

Health

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Assignment

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