Patient case (written or verbal) content is dependent on the care setting and preceptor expectations. Any Improvement” or Deficiency” is subject to revision/remediation at the preceptor’s discretion. “Needs “Significant Exceeds Competency (4 points) Meets Competency (3 points) Needs Improvement (2 points) Significant Deficiency (1 point) Subjective/Objective All necessary information Most information is collected Substantial pertinent Inaccurate information or lack Include (may be site specific): collected with omissions information is missing from the of critical pertinent Age, gender, date of Information is accurate Information is accurate presentation, but would not information may cause patient admission/visit Information is pertinent with Most information is pertinent; cause patient harm harm CC/reason for presentation little extraneous information some extraneous data Some inaccurate information, Information is significantly HPI or hospital course Information presented in a included but not cause patient harm disorganized PMH logical order Information is presented in a Substantial extraneous Pertinent Surgical History mostly logical order information included Pertinent Family History Presentation of information is Social History (e.g. TOB and somewhat disorganized EtOH use, preferences, socioeconomic factors) Maintenance/Preventive care (e.g. vaccinations) Allergies/intolerances to medications and reactions Medications (home, current, past, dose changes, etc.) Vital signs Pertinent +/- PE/ROS and/or diagnostic test findings Pertinent +/- lab findings Performance: _____ points Assessment All pertinent problems are Most problems are identified Some problems not identified Problems listed by disease identified Most problems appropriately Problem prioritization is state/condition All problems appropriately prioritized somewhat inappropriate prioritized by acuity/severity Most problems assessed Some assessments (problems, Medication assessment should Assessment for each problem is appropriately with minor meds) are incomplete or include (may be site specific): complete & supported by omissions of S/O data inappropriate, but would not - Regimen relevant S/O information Most medications are result in patient harm - Adherence/missed or held doses All meds are correctly grouped correctly grouped by problem Several medications incorrectly - Administration considerations by problem Most medication assessments grouped by problem - Duration, when applicable All meds are assessed are appropriate with minor - Effectiveness comprehensively & omissions - Safety appropriately
Patient case (written or verbal) content is dependent on the care setting and preceptor expectations. Any “Needs Improvement” or “Significant Deficiency” is subject to revision/remediation at the preceptor’s discretion. Exceeds Competency (4 points) Meets Competency (3 points) Needs Improvement (2 points) Significant Deficiency (1 point) Subjective/Objective Include (may be site specific): Age, gender, date of admission/visit CC/reason for presentation HPI or hospital course PMH Pertinent Surgical History Pertinent Family History Social History (e.g. TOB and EtOH use, preferences, socioeconomic factors) Maintenance/Preventive care (e.g. vaccinations) Allergies/intolerances to medications and reactions Medications (home, current, past, dose changes, etc.) Vital signs Pertinent +/- PE/ROS and/or diagnostic test findings Pertinent +/- lab findings Performance: _____ points All necessary information collected Information is accurate Information is pertinent with little extraneous information Information presented in a logical order Most information is collected with omissions Information is accurate Most information is pertinent; some extraneous data included Information is presented in a mostly logical order Substantial pertinent information is missing from the presentation, but would not cause patient harm Some inaccurate information, but not cause patient harm Substantial extraneous information included Presentation of information is somewhat disorganized Inaccurate information or lack of critical pertinent information may cause patient harm Information is significantly disorganized Assessment Problems listed by disease state/condition Medication assessment should include (may be site specific): - Regimen - Adherence/missed or held doses - Administration considerations - Duration, when applicable - Effectiveness - Safety All pertinent problems are identified All problems appropriately prioritized by acuity/severity Assessment for each problem is complete & supported by relevant S/O information All meds are correctly grouped by problem All meds are assessed comprehensively & appropriately Most problems are identified Most problems appropriately prioritized Most problems assessed appropriately with minor omissions of S/O data Most medications are correctly grouped by problem Most medication assessments are appropriate with minor omissions Some problems not identified Problem prioritization is somewhat inappropriate Some assessments (problems, meds) are incomplete or inappropriate, but would not result in patient harm Several medications incorrectly grouped by problem
S-207%2FU-13799-46101-90448%2F1466533616_Patient_Case_Rubric_03_16.docx