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