|
Chief
Complaint (Reason for seeking health care) – S
|
Distinguished
Includes a direct
quote from patient about presenting problem
4
pts
Excellent
Includes a direct
quote from patient and other unrelated information
3
pts
Fair
Includes information
but information is NOT a direct quote
2
pts
Poor
Information is
completely missing
0
pts
|
/4 pts
|
|
Demographics
– S
|
Distinguished
Begins with patient
initials, age, race, ethnicity and gender (5 demographics)
2
pts
Excellent
Begins with 4 of the 5
patient demographics (patient initials, age, race, ethnicity and gender)
1.5
pts
Fair
Begins with 3 or less
patient demographics (patient initials, age, race, ethnicity and gender)
1
pts
Poor
Information is
completely missing
0
pts
|
/2 pts
|
|
History
of the Present Illness (HPI) – S
|
Distinguished
Includes the
presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset,
Location, Duration, Character, Aggravating factors, Relieving factors, Timing
and Severity)
4
pts
Excellent
Includes the
presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character, Aggravating factors, Relieving factors,
Timing and Severity)
3
pts
Fair
Includes the
presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character, Aggravating factors, Relieving factors,
Timing and Severity)
2
pts
Poor
Information is
completely missing
0
pts
|
/4 pts
|
|
Allergies
– S
|
Distinguished
Includes NKA
(including = Drug, Environemental, Food, Herbal, and/or Latex or if allergies
are present (reports for each severity of allergy AND description of allergy)
2
pts
Excellent
If allergies are
present, students lists type Drug, environemtal factor, herbal, food, latex
name and includes severity of allergy OR description of allergy
1.5
pts
Fair
If allergies are
present, students lists only the type of allergy name
1
pts
Poor
Information is
completely missing
0
pts
|
/2 pts
|
|
Review
of Systems (ROS) – S
|
Distinguished
Includes a minimum of
3 assessments for each body system and assesses at least 9 body systems
directed to chief complaint AND uses the words “admits” and “denies”
9
pts
Excellent
Includes 3 or fewer
assessments for each body system and assesses 5-8 body systems directed to
chief complaint AND uses the words “admits” and “denies”
7
pts
Fair
Includes 3 or fewer
assessments for each body system and assesses less than 5 body systems
directed to chief complaint OR student does not use the words “admits” and
“denies”
5
pts
Poor
Information is
completely missing
0
pts
|
/9 pts
|
|
Vital
Signs – O
|
Distinguished
Includes all 8 vital
signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or
Celsius and route of temperature collection), weight, height, BMI (or
percentiles for pediatric population) and pain.)
2
pts
Excellent
Includes 7 vital
signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or
Celsius and route of temperature collection), weight, height, BMI (or
percentiles for pediatric population) and pain.)
1.5
pts
Fair
Includes 6 or less
vital signs, (BP (with patient position), HR, RR, temperature (with
Fahrenheit or Celsius and route of temperature collection), weight, height,
BMI (or percentiles for pediatric population) and pain.)
1
pts
Poor
Information is
completely missing
0
pts
|
/2 pts
|
|
Labs
– O
|
Distinguished
Includes a list of the
labs reviewed at the visit, values of lab results and highlights abnormal
values OR acknowledges no labs/diagnostic tests were reviewed.
3
pts
Excellent
Includes a list of the
labs reviewed at the visit, values of lab results but does not highlight
abnormal values.
2
pts
Fair
Includes a list of the
labs reviewed at the visit but does not include the values of lab results or
highlight abnormal values.
1
pts
Poor
Information is
completely missing
0
pts
|
/3 pts
|
|
Medications
– O
|
Distinguished
Includes a list of all
of the patient reported medications and the medical diagnosis for the
medication (including name, dose, route, frequency)
4
pts
Excellent
Includes a list of all
of the patient reported medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose, medications route, frequency)
2
pts
Fair
Includes a list of all
of the patient reported medications (including 2 of the 4: name, dose, route,
frequency)
1
pts
Poor
Information is
completely missing
0
pts
|
/4 pts
|
|
Screenings
– O
|
Distinguished
Includes an assessment
of at least 5 screening tests
3
pts
Excellent
Includes an assessment
of at least 4 screening tests
2
pts
Fair
Includes each medical diagnosis
but does not include year of diagnosis or whether the diagnosis is active or
current OR does not include a medical diagnosis for each medication listed
under medications.
1
pts
Poor
Information is
completely missing
0
pts
|
/3 pts
|
|
Past
Medical History – O
|
Distinguished
Includes, for each
medical diagnosis, year of diagnosis and whether the diagnosis is active or
current AND there is a medical diagnosis for each medication listed under
medications
3
pts
Excellent
Includes, for each
medical diagnosis, either year of diagnosis OR whether the diagnosis is
active or current AND there is a medical diagnosis for each medication listed
under medications
2
pts
Fair
Includes, for each
medical diagnosis, either year of diagnosis OR whether the diagnosis is active
or current AND there is a medical diagnosis for each medication listed under
medications
1
pts
Poor
Information is
completely missing
0
pts
|
/3 pts
|
|
Past
Surgical History – O
|
Distinguished
Includes, for each
surgical procedure, the year of procedure and the indication for the
procedure
3
pts
Excellent
Includes, for each
surgical procedure, the year of procedure OR indication of the procedure
2
pts
Fair
Includes, for each
surgical procedure but not the year of procedure or indication of the
procedure
1
pts
Poor
Information is
completely missing
0
pts
|
/3 pts
|
|
Family
History – O
|
Distinguished
Includes an assessment
of at least 4 family members regarding, at a minimum, genetic disorders,
diabetes, heart disease and cancer.
3
pts
Excellent
Includes an assessment
of at least 3 family members regarding, at a minimum, genetic disorders,
diabetes, heart disease and cancer.
2
pts
Fair
Includes an assessment
of at least 2 family members regarding, at a minimum, genetic disorders,
diabetes, heart disease and cancer.
1
pts
Poor
Information is
completely missing
0
pts
|
/3 pts
|
|
Social
History – O
|
Distinguished
Includes all 11 of the
following: tobacco use, drug use, alcohol use, marital status, employment
status, current and previous occupation, sexual orientation, sexually active,
contraceptive use, and living situation.
3
pts
Excellent
Includes 10 of the 11
following: tobacco use, drug use, alcohol use, marital status, employment
status, current and previous occupation, sexual orientation, sexually active,
contraceptive use, and living situation.
2
pts
Fair
Includes 9 or less of
the following: tobacco use, drug use, alcohol use, marital status, employment
status, current and previous occupation, sexual orientation, sexually active,
contraceptive use, and living situation.
1
pts
Poor
Information is
completely missing
0
pts
|
/3 pts
|
|
Physical
Examination – O
|
Distinguished
Includes a minimum of
4 assessments for each body system and assesses at least 5 body systems
directed to chief complaint
9
pts
Excellent
Includes a minimum of
3 assessments for each body system and assesses at least 4 body systems
directed to chief complaint
7
pts
Fair
Includes a minimum of
2 assessments for each body system and assesses at least 4 body systems
directed to chief complaint
5
pts
Poor
Information is
completely missing
0
pts
|
/9 pts
|
|
Diagnosis
– A
|
Distinguished
Includes a clear
outline of the accurate principal diagnosis AND lists the remaining diagnoses
addressed at the visit (in descending priority)
5
pts
Excellent
Includes a clear outline
of the accurate diagnoses addressed at the visit but does not list the
diagnoses in descending order of priority
3
pts
Fair
Includes an inaccurate
diagnosis as the principal diagnosis
2
pts
Poor
Information is
completely missing
0
pts
|
/5 pts
|
|
Differential
Diagnosis – A
|
Distinguished
Includes at least 3
differential diagnoses for the principal diagnosis
5
pts
Excellent
Includes 2
differential diagnoses for the principal diagnosis
3
pts
Fair
Includes 1
differential diagnosis for the principal diagnosis
2
pts
Poor
Information is
completely missing
0
pts
|
/5 pts
|
|
Pharmacologic
treatment plan – P
|
Distinguished
Includes a detailed
pharmacologic treatment plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of the following: drug name, dose, route,
frequency, duration and cost as well as education related to pharmacologic
agent. If the diagnosis is a chronic problem, student includes instructions
on currently prescribed medications as above.
4
pts
Excellent
Includes a detailed
pharmacologic treatment plan for each of the diagnoses listed under
“assessment”. The plan includes 4 of the following 7: the drug name, dose,
route, frequency, duration and cost as well as education related to
pharmacologic agent. If the diagnosis is a chronic problem, student includes
instructions on currently prescribed medications as above.
3
pts
Fair
Includes a detailed
pharmacologic treatment plan for each of the diagnoses listed under
“assessment”. The plan includes less than 4 of the following: the drug name,
dose, route, frequency, duration and cost as well as education related to
pharmacologic agent. If the diagnosis is a chronic problem, student includes
instructions on currently prescribed medications as above.
2
pts
Poor
Information is completely
missing
0
pts
|
/4 pts
|
|
Diagnostic/Lab
Testing – P
|
Distinguished
Includes appropriate
diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic
testing clinically required at this time”
5
pts
Excellent
Includes appropriate
diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing
clinically required at this time”
3
pts
Fair
Includes appropriate
diagnostic testing less than 50% of the time.
2
pts
Poor
Information is
completely missing
0
pts
|
/5 pts
|
|
Education
– P
|
Distinguished
Includes at least 3
strategies to promote and develop skills for managing their illness and at
least 3 self-management methods on how to incorporate healthy behaviors into
their lives.
5
pts
Excellent
Includes at least 2
strategies to promote and develop skills for managing their illness and at
least 2 self-management methods on how to incorporate healthy behaviors into
their lives.
3
pts
Fair
Includes at least 1
strategies to promote and develop skills for managing their illness and at
least 1 self-management methods on how to incorporate healthy behaviors into
their lives.
2
pts
Poor
Information is
completely missing
0
pts
|
/5 pts
|
|
Anticipatory
Guidance – P
|
Distinguished
Includes at least 3
primary prevention strategies (related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory guidance)) and at least 2
secondary prevention strategies (related to age/condition (i.e. screening))
4
pts
Excellent
Includes at least 2
primary prevention strategies (related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory guidance)) and at least 2
secondary prevention strategies (related to age/condition (i.e. screening))
2
pts
Fair
Includes at least 1
primary prevention strategies (related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory guidance)) and at least 1
secondary prevention strategies (related to age/condition (i.e. screening))
1
pts
Poor
Information is
completely missing
0
pts
|
/4 pts
|
|
Follow
up plan – P
|
Distinguished
Includes
recommendation for follow up, including time frame (i.e. x # of
days/weeks/months)
4
pts
Excellent
Includes
recommendation for follow up, but does not include time frame (i.e. x # of
days/weeks/months)
2
pts
Poor
Does not include
follow up plan
0
pts
|
/4 pts
|
|
References
|
Distinguished
High level of APA
precision
3
pts
Excellent
Moderate level of APA
precision
2
pts
Fair
Incorrect APA style
1
pts
Poor
Information is
completely missing
0
pts
|
/3 pts
|
|
Grammar
|
Distinguished
Free of grammar and
spelling errors
3
pts
Excellent
Writing mechanics need
more precision and attention to detail
2
pts
Poor
Writing mechanics need
serious attention
0
pts
|
/3 pts
|
|
Incorporation
of Current Practice Guidelines
|
Distinguished
Includes recommendations
from at least 1 professional set of practice guidelines (although not the
current version)
4
pts
Excellent
Includes 2 or fewer
recommendations from at least 1 current, professional set of practice
guidelines
3
pts
Fair
Includes
recommendations from at least 1 professional set of practice guidelines
(although not the current version)
2
pts
Poor
Information is
completely missing or student includes a non-credible set of treatment
guidelines
0
pts
|
/4 pts
|
|
Role
of the Nurse Practitioner
|
Distinguished
Includes a discussion
of the role of NP pertaining to the assessment, work up, collaboration and
management of the case presented AND gives at least 1 example pertaining to
each of the 4 areas (assessment, work up, collaboration and management).
4
pts
Excellent
Includes a discussion
of the role of NP pertaining to the assessment, work up, collaboration and
management of the case presented AND gives atleast 1 example pertaining to 2
of the 4 areas (assessment, work up, collaboration and management).
3
pts
Fair
Does not include a
discussion of the role of NP pertaining to the assessment, work up,
collaboration and management of the case presented OR give at least 1 example
pertaining to 3 or more of the following areas (assessment, work up,
collaboration and management).
2
pts
Poor
Information is
completely missing
0
pts
|
/4 pts
|
