case analysis project

Rubric

Student Name

Score

PATIENT DESCRIPTION AND DEMOGRAPHICS

(5%) (Gender, Age, Race, Height, Weight

and/or BMI, Orientation, Marital Status: If

single, do you live alone? If married, how

many years?, Children, Grandchildren,

Occupation including work duties, Self-

Presentation/Appearance)

Provided complete, accurate data and asked relevant questions during history-taking 5%

Provided relevant, accurate, but incomplete data 3%

Provides severely incomplete, inaccurate, irrelevant, or no data 0%

CASE CHIEF COMPLAINT (5%): (does not

include actual diagnosis)

PRESENTING SITUATION (5%): (write a few

sentences about the patient’s presenting

problem)

CHIEF COMPLAINT Provides a chief complaint without a leading question

5% Did not provide a chief complaint

0%

PRESENTING SITUATION Provides a complete, relevant, accurate presenting situation derived from the patient

5% Provides incomplete or inaccurate presenting situation or did not ask relevant questions from

patient 3%

Provides no data 0%

SUBJECTIVE INFORMATION (20%): (provide

chief complaint, secondary complaints if any,

mechanism of injury, thorough medical

history, previous

medical/psychiatric/therapeutic histories,

history of physical activity and exercise,

Provides complete, relevant, accurate subjective information consistent with the history 20%

Provides relevant, accurate, but incomplete subjective data consistent with the history 15%

Provides relevant, accurate, but incomplete subjective data, but is inconsistent with the history 10%

Information is either irrelevant, inaccurate, and/or is inconsistent with history

perspectives towards physical therapy, sleep

disturbance/sleep patterns, nutrition status,

perspectives on movement in general) *use

scales/measures if necessary)

0%

PSYCHOSOCIAL STATUS (10%): (economic

status, work/employment status, family and

current support systems, relationship status,

substance abuse history, positive support

systems)

Provides complete, accurate psychological status with information relevant to the patient and their case

10% Psychological status is either incomplete, is inaccurate or is irrelevant to the case

5% Provides no psychosocial information

0%

OBJECTIVE INFORMATION (30%): (perform the

objective tests you deem necessary and

important for this case)

Objective tests are complete and relevant, are based on subjective information gathered, and are patient-specific.

30% Objective information is lacking in relevant areas but is consistent with the subjective

information gathered, and is patient-specific. Slightly incomplete. 25%

Objective information is somewhat complete but is inconsistent with the subjective information gathered, and not completely patient-specific or irrelevant tests were performed.

20% Several crucial objective tests were not performed or were not consistent with subjective

information. Contains a significant amount of irrelevant tests. 10%

Objective tests are generic, not patient-centered, and focused on diagnosis as opposed to patient-identified movement-related issues. Severely lacks crucial assessments.

0 %

DIFFERENTIAL SCREENING (10%): (general

systems screening, yellow and red flag

screening, list competing diagnostic

possibilities)

Provided a list of competing diagnostic possibilities and how they were ruled out and screened for general health issues as well as yellow and red flags.

10% Screened for general health issues, as well as yellow and red flags. Did not list nor rule out

competing diagnostic possibilities. 5%

Either did not provide a list of diagnostic possibilities, did not provide yellow and red flags, or did not perform a general systems screen.

0%

ACTUAL DIAGNOSIS (5%): As provided by the

referring physician, if any.

Provided a medical diagnosis, or mentioned that one was not provided in the history or written document

5% Incomplete medical diagnosis or did not provide a medical diagnosis but did not mention that

it was not provided nor available in patient history or within documentation 0%

PHYSICAL THERAPY DIAGNOSIS (10%): (write

the physical therapy diagnosis you have for

the patient given the course’s model)

Provided a physical therapy diagnosis in the correct format (see PowerPoint Week 12) consistent with accepted ICF guidelines.

10% Provided a physical therapy diagnosis however it is either incomplete or incorrectly formatted

5% Did not provide a physical therapy diagnosis or utilized a medical diagnosis as a PT diagnosis

0%

Total