presentation : | Nursing

Clinical Requirement:

RUBRIC.docx Case Study Rubric 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