Current Regis Time
| Rubric Criteria | Full Completion | Partial Completion | Not Included | Total Points |
|---|---|---|---|---|
| General | Identifying Data (1%) Source and Reliability of history (1%) Chief complaint (also known as history of present illness-HPI) or reason for visit (1%) Past Medical History (1%) Past Surgical History (1%) Social History (1%) Family History (1%) Medications (1%) Allergies (1%) Spelling and grammar are accurate (1%) (10 points) |
Partial Completion (8 points) |
Not included (0 points) |
10 |
| Subjective Data | Information is accurate and organized (5%) Assessment done were appropriate and complete for the chief complaint and associated systems (15%) Documented using proper terminology and format (5%) Spelling and grammar are accurate (5%) (30 points) |
Partial Completion (26 points) |
Not included (0 points) |
30 |
| Objective Data | Information is accurate and organized (5%) Assessments done were appropriate and complete for the chief complaint and associated systems (15%) Documented using proper terminology and format (5%) Spelling and grammar are accurate (5%) (30 points) |
Partial Completion (26 points) |
Not included (0 points) |
30 |
| Assessment | Provides differential list (at least 3) with brief rationale for each differential (15%) Identifies most likely diagnosis based on subjective and objective data (not included in the differential list)(5%) (20 points) |
Partial Completion (18 points) |
Not included (0 points) |
20 |
| Plan | Formulates plan for the diagnosis listed above Includes: Appropriate diagnostic tests (2%) Pharmacologic interventions (2%) Non-pharmacologic interventions (2%) Referrals (1%) Education (2%) Follow-up (1%) (10 points) |
Partial Completion (8 points) |
Not included (0 points) |
10 |
| Total points | 100 | |||