Mod 6 FHP PP

Case Study Rubric Criteria

-Chief Complaint (Reason for seeking health care) - S

Includes a direct quote from patient about presenting problem

-Demographics - S

Begins with patient initials, age, race, ethnicity and gender (5 demographics)

-History of the Present Illness (HPI) - S

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

-Allergies - S

Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)

-Review of Systems (ROS) - S

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”

-Vital Signs - O

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.)

-Labs - O

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.

-Medications - O

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)

-Screenings - O

Includes an assessment of at least 5 screening tests

-Past Medical History - O

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

-Past Surgical History - O

Includes, for each surgical procedure, the year of procedure and the indication for the procedure

-Family History - O

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

-Social History - O

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.

-Physical Examination - O

Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint

-Diagnosis - A

Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)

-Differential Diagnosis - A

Includes at least 3 differential diagnoses for the principal diagnosis

-Pharmacologic treatment plan - P

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.

-Diagnostic/Lab Testing - P

Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”

-Education - P

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.

-Anticipatory Guidance - P

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))

-Follow up plan - P

Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)

-References

High level of APA precision

-Grammar

Free of grammar and spelling errors

-Incorporation of Current Practice Guidelines

Includes recommendations from at least 1 professional set of practice guidelines (although not the current version)

-Role of the Nurse Practitioner

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).