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
