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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

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