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Clinical Case Study
Clinical Case Study
This rubric is designed for assessment of a clinical case study.
Rubric Code:
Z8242X
By
lakisharredmond
Ready to use
Public Rubric
Subject:
Medical
Type:
Writing
Grade Levels:
Graduate
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I. History I
Unacceptable
0 pts
Marginally Acceptable
5 pts
Satisfactory
7.5 pts
Exceptional
15 pts
Chief Complaint (CC) and HPI
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)
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)
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
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.
Keywords:
Nurse Practitioner
Subjects:
Medical
Types:
Writing
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