Academic H & P note

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Academic Clinical History and Physical Note - Rubric

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History and Physical Note

10 points

Criteria Description

History and Physical Note (Chief Complaint, HPI, Patient History, Home Medications, Review of Systems, Vital Signs, Physical Exam, Test Results)

5. Target

10 points

The history and physical note is thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

9 points

The history and physical note is provided with appropriate details and support.

3. Approaching

8 points

The history and physical note is present, but only minimal detail or support is provided.

2. Insufficient

5 points

The history and physical note is incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The history and physical note is not included.

Assessment and Clinical Impressions

10 points

Criteria Description

Assessment and Clinical Impressions (Identification of Three Differential Diagnoses, List of Acute and Chronic Diagnoses, List of Diagnoses and Conditions in Priority Order)

5. Target

10 points

The assessment and clinical impressions are thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

9 points

The assessment and clinical impressions are provided with appropriate details and support.

3. Approaching

8 points

The assessment and clinical impressions are present, but only minimal detail or support is provided.

2. Insufficient

5 points

The assessment and clinical impressions are incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The assessment and clinical impressions are not included.

Plan and Criteria Incorporation

10 points

Criteria Description

Plan Component Management and Criteria Incorporation (Interventions, Disposition, Expected Outcomes, Health Education, and Case Summary)

5. Target

10 points

The plan component management and plan criteria incorporation are thoroughly explored and clearly explained with relevant details and support.

4. Acceptable

9 points

The plan component management and plan criteria incorporation are provided with appropriate details and support.

3. Approaching

8 points

The plan component management and plan criteria incorporation are present, but only minimal detail or support is provided.

2. Insufficient

5 points

The plan component management and plan criteria incorporation are incomplete or otherwise deficient.

1. Unsatisfactory

0 points

The plan component management and plan criteria incorporation are not included.

Peer-Reviewed Articles

10 points

Criteria Description

Peer-Reviewed Articles

5. Target

10 points

Three peer-reviewed articles are included.

4. Acceptable

9 points

N/A

3. Approaching

8 points

N/A

2. Insufficient

5 points

Fewer than three peer-reviewed articles are provided.

1. Unsatisfactory

0 points

Three peer-reviewed articles are not included.

Mechanics of Writing

5 points

Criteria Description

Includes spelling, punctuation, grammar, language use.

5. Target

5 points

Writer is clearly in command of standard, written, academic English.

4. Acceptable

4.5 points

Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.

3. Approaching

4 points

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.

2. Insufficient

2.5 points

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

1. Unsatisfactory

0 points

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

Format/Documentation

5 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

5. Target

5 points

No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.

4. Acceptable

4.5 points

Appropriate format and documentation are used with only minor errors.

3. Approaching

4 points

Appropriate format and documentation are used, although there are some obvious errors.

2. Insufficient

2.5 points

Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.

1. Unsatisfactory

0 points

Appropriate format is not used. No documentation of sources is provided.

Total 50 points