4 pts
Distinguished Includes a direct quote from patient about presenting problem |
3 pts
Excellent Includes a direct quote from patient and other unrelated information |
2 pts
Fair Includes information but information is NOT a direct quote |
0 pts
Poor Information is completely missing |
2 pts
Distinguished Begins with patient initials, age, race, ethnicity and gender (5 demographics) |
1.5 pts
Excellent Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender) |
1 pts
Fair Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) |
0 pts
Poor Information is completely missing |
4 pts
Distinguished Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) |
3 pts
Excellent Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) |
2 pts
Fair Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) |
0 pts
Poor Information is completely missing |
2 pts
Distinguished 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) |
1.5 pts
Excellent If allergies are present, students lists type Drug, environemtal factor, herbal, food, latex name and includes severity of allergy OR description of allergy |
1 pts
Fair If allergies are present, students lists only the type of allergy name |
0 pts
Poor Information is completely missing |
9 pts
Distinguished 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” |
7 pts
Excellent Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies” |
5 pts
Fair Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies” |
0 pts
Poor Information is completely missing |
2 pts
Distinguished 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.) |
1.5 pts
Excellent Includes 7 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.) |
1 pts
Fair Includes 6 or less 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.) |
0 pts
Poor Information is completely missing |
3 pts
Distinguished 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. |
2 pts
Excellent Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values. |
1 pts
Fair Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values. |
0 pts
Poor Information is completely missing |
4 pts
Distinguished Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency) |
2 pts
Excellent Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency) |
1 pts
Fair Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency) |
0 pts
Poor Information is completely missing |
3 pts
Distinguished Includes an assessment of at least 5 screening tests |
2 pts
Excellent Includes an assessment of at least 4 screening tests |
1 pts
Fair Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current OR does not include a medical diagnosis for each medication listed under medications. |
0 pts
Poor Information is completely missing |
3 pts
Distinguished 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 |
2 pts
Excellent Includes, for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current AND there is a medical diagnosis for each medication listed under medications |
1 pts
Fair Includes, for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current AND there is a medical diagnosis for each medication listed under medications |
0 pts
Poor Information is completely missing |
3 pts
Distinguished Includes, for each surgical procedure, the year of procedure and the indication for the procedure |
2 pts
Excellent Includes, for each surgical procedure, the year of procedure OR indication of the procedure |
1 pts
Fair Includes, for each surgical procedure but not the year of procedure or indication of the procedure |
0 pts
Poor Information is completely missing |
3 pts
Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. |
2 pts
Excellent Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. |
1 pts
Fair Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. |
0 pts
Poor Information is completely missing |
3 pts
Distinguished 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. |
2 pts
Excellent Includes 10 of the 11 following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. |
1 pts
Fair Includes 9 or less 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. |
0 pts
Poor Information is completely missing |
9 pts
Distinguished Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint |
7 pts
Excellent Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint |
5 pts
Fair Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint |
0 pts
Poor Information is completely missing |
5 pts
Distinguished Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) |
3 pts
Excellent Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority |
2 pts
Fair Includes an inaccurate diagnosis as the principal diagnosis |
0 pts
Poor Information is completely missing |
5 pts
Distinguished Includes at least 3 differential diagnoses for the principal diagnosis |
3 pts
Excellent Includes 2 differential diagnoses for the principal diagnosis |
2 pts
Fair Includes 1 differential diagnosis for the principal diagnosis |
0 pts
Poor Information is completely missing |
4 pts
Distinguished 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. |
3 pts
Excellent Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following 7: the 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. |
2 pts
Fair Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the following: the 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. |
0 pts
Poor Information is completely missing |
5 pts
Distinguished Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time” |
3 pts
Excellent Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time” |
2 pts
Fair Includes appropriate diagnostic testing less than 50% of the time. |
0 pts
Poor Information is completely missing |
5 pts
Distinguished 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. |
3 pts
Excellent Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives. |
2 pts
Fair Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives. |
0 pts
Poor Information is completely missing |
4 pts
Distinguished 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)) |
2 pts
Excellent Includes at least 2 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)) |
1 pts
Fair Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening)) |
0 pts
Poor Information is completely missing |
4 pts
Distinguished Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months) |
2 pts
Excellent Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months) |
0 pts
Poor Does not include follow up plan |
3 pts
Distinguished High level of APA precision |
2 pts
Excellent Moderate level of APA precision |
1 pts
Fair Incorrect APA style |
0 pts
Poor Information is completely missing |
3 pts
Distinguished Free of grammar and spelling errors |
2 pts
Excellent Writing mechanics need more precision and attention to detail |
0 pts
Poor Writing mechanics need serious attention |
4 pts
Distinguished Includes recommendations from at least 1 professional set of practice guidelines (although not the current version) |
3 pts
Excellent Includes 2 or fewer recommendations from at least 1 current, professional set of practice guidelines |
2 pts
Fair Includes recommendations from at least 1 professional set of practice guidelines (although not the current version) |
0 pts
Poor Information is completely missing or student includes a non-credible set of treatment guidelines |
4 pts
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). |
3 pts
Excellent Includes a discussion of the role of NP pertaining to the assessment, work up, collaboration and management of the case presented AND gives atleast 1 example pertaining to 2 of the 4 areas (assessment, work up, collaboration and management). |
2 pts
Fair Does not include a discussion of the role of NP pertaining to the assessment, work up, collaboration and management of the case presented OR give at least 1 example pertaining to 3 or more of the following areas (assessment, work up, collaboration and management). |
0 pts
Poor Information is completely missing |
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