NURS6305 Women Reproductve system

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Advanced Assessment Grading Rubric for SOAP Case Study Documentation

Criteria

Exceeds Criteria 30 pts

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Meets Criteria 20-25 pts

Needs Improve 15-20 pts

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Unsatisfactory< 14 pts

Subjective 30 pts

CC 5pts HPI 5 pts FMH 5 pts SH 5 pts ROS 10 pts

Data recorded is based on information gathered from health history, medical records, family sources, external records. All recorded data is subjective. All subjective data is collected and is comprehensive.

Data is recorded based on information gathered from health history. All data is subjective. All subjective data collected and is complete The health history/subjective information gathered is consistent to make a working diagnosis

Data recorded is partially based on history. Some data recorded does not indicate source. Did not complete all aspects of subjective data collection. Did complete all aspects of subjective data collection but very superficially, lacking depth.

Medical terminology is not consistently used. There are misspellings in terminology. Subjective and Objective Data is mixed up. The subjective data does not match with the objective data collected. Subjective data is missing based on CC

Objective – 30 pts

Physical Exam to include inspection, palpation, percussion, auscultation (20 pts)

Indicated physical exam modalities (5 pts)

Diagnostic lab results and Diagnostic imaging results (5 pts)

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Correct medical terminology is used and spelled correctly. All recorded data is objective. Documentation clearly describes in detail all physical findings from physical exam. Documentation is comprehensive, complete and includes all physical modalities.

Correct medical terminology is used. All recorded data is objective. Documentation describes most physical findings. Documentation is complete and includes all physical modalities.

Medical terminology is not consistently used. An occasional subjective data is recorded with objective data. Documentation of physical findings are present but incomplete.

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Medical terminology not used consistently. Subjective data and objective data are mixed up.

The documentation does not clearly describe the physical findings. Documentation is missing.

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Assessment –10 pts

Diagnosis to include ICD 10 code

Clear justification for working diagnosis. Includes all primary and secondary problems. Ruled in diagnosis. Ruled out differential diagnosis. Listed diagnosis from acute, comprehensive to chronic or benign last. ICD 10 codes included and are specific. 10 pts

Justification for working diagnosis can be determined. Included primary problems. Included some secondary problems. ICD 10 codes included but are unspecified.

7-9 pts

There is incomplete justification for working diagnosis.

The diagnosis is not supported by the subjective and objective data collected. ICD 10 code present

5-6 pts

The working diagnosis is incorrect. Fails to clearly justify primary diagnosis. Fails to note secondary problems/diagnosis.

ICD 10 code is missing

< 4 pts

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Plan – 30 pts

Evidence Based Practice Guidelines Treatment (5 pt)

Medications (use of first line medications) (5 pt)

Education (patient and family as indicated)

(5 pt)

Health Promotion/Disease Prevention across the Lifespan (5 pts)

Inter professional Collaboration & Referrals if indicated (5pt)

Follow up (5 pt)

Highly cost effective when ordering diagnostic tests and therapeutic orders. Elicits patient’s perspective. Treatment plans and medications are cost effective and covered by patient’s insurance carrier. Interactions with other Rx, OTC, CAM, and diet are considered. Prescriptions are correctly written including correct medication, correct dose. Treatment recommendations and patient education address all issues raised by diagnosis and are individualized, evidence based interventions. Lifespan considerations included. Anticipatory guidance/health promotion included. Referrals are specific as to who, when, why. Timing and type of follow up is thoughtfully addressed.

Cost effective when ordering diagnostic tests.

Treatment plans and medications are cost effective.

Interactions with other medications and OTC are considered.

Prescriptions are correctly written.

Treatment recommendations and patient education address most issues raised by diagnosis.

Treatment options are evidence based interventions.

Lifespan considerations included. Anticipatory guidance addressed as well as health promotion. Referral included. Follow up is addressed.

Costs are not considered.

Treatment plan may not be covered by patient’s insurance.

Medications may not be covered.

Prescriptions are written partially correct – needing correction to dose.

Minimal patient education

No inter collaboration referrals are considered.

Minor anticipatory guidance.

Follow up is addressed by timing or type of follow up is suboptimal.

Incomplete or inappropriate plan of care.

Treatment plans are effective. May be evidence based or best practice.

Costs are not considered. Therapies and medications may or may not be covered by patients insurance. Prescription is not written correctly. Inappropriate medications ordered. Allergies or other patient variables conflict with medications prescribed.

Minimal patient education or not addressed.

No anticipatory guidance. No lifespan considerations.

Minimal non pharmacological therapy.

No follow up is indicated.

Organization

(Considered for all points)

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All information is neat organized in a logical sequence with correct spelling. Bullet format

Information is generally organized in a logical sequence. Used bullets

Minor errors in format. Information is somewhat organized. Used paragraphs

Misspelling present.

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