presentation

Case Study Rubric

Criteria

Ratings

Points

Chief Complaint (Reason for seeking health care) - S

Includes a direct quote from patient about presenting problem

/4 pts

Demographics - S

Begins with patient initials, age, race, ethnicity and gender

(5 demographics)

/2 pts

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)

/4 pts

Allergies - S

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

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”

/9 pts

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.)

/2 pts

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.

/3 pts

Medications - O

Includes a list of all of the patient reported medications and the medical

diagnosis for the medication (including name, dose, route, frequency)

/4 pts

Screenings - O

Includes an assessment of at least 5 screening tests

/3 pts

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

/3 pts

Past Surgical History - O

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

/3 pts

Family History - O

Includes an assessment of at least 4 family members regarding,

at a minimum, genetic disorders, diabetes, heart disease and cancer.

/3 pts

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.

/3 pts

Physical Examination - O

Includes a minimum of 4 assessments for each body system and assesses

at least 5 body systems directed to chief complaint

/9 pts

Diagnosis - A

Includes a clear outline of the accurate principal diagnosis AND lists

the remaining diagnoses addressed at the visit (in descending priority)

/5 pts

Differential Diagnosis - A

Includes at least 3 differential diagnoses for the principal diagnosis

/5 pts

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.

/4 pts

Diagnostic/Lab Testing - P

Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges

“no diagnostic testing clinically required at this time”

/5 pts

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.

/5 pts

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))

/4 pts

Follow up plan - P

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

/4 pts

References

High level of APA precision

/3 pts

Grammar

Free of grammar and spelling errors

/3 pts

Incorporation of Current Practice Guidelines

Includes recommendations from at least 1 professional set of practice

guidelines (although not the current version)

/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