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Begins with patient initials, age, race, ethnicity and gender (5 demographics)

Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)

Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)

Missing criteria and/or submission.

Includes a direct quote from patient about presenting problem

Includes a direct quote from patient and other unrelated information

Includes information but information is NOT a direct quote

Missing criteria and/or submission.

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

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)

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)

Missing criteria and/or submission.

Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)

If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy

If allergies are present, students lists only the type of allergy name

Missing criteria and/or submission.

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”

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”

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”

Missing criteria and/or submission.

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.)

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.)

Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)

Missing criteria and/or submission.

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.

Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.

Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.

Missing criteria and/or submission.

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)

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)

Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)

Missing criteria and/or submission.

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current

Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current

Missing criteria and/or submission.

Includes, for each surgical procedure, the year of procedure and the indication for the procedure

Includes, for each surgical procedure, the year of procedure OR indication of the procedure

Includes, for each surgical procedure but not the year of procedure or indication of the procedure

Missing criteria and/or submission.

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

Missing criteria and/or submission.

Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

Includes 9 or less of the required information.

Missing criteria and/or submission.

Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests

Includes a partial assessment of immunization status and health maintenance needs, missing some key components. Includes an assessment of at least 4 screening tests

Includes minimal assessment of immunization status and health maintenance needs, lacking detail. Includes an assessment of at least 3 screening tests

Missing criteria and/or submission.

Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint

Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint

Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint

Missing criteria and/or submission.

Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)

Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority

Includes 1 differential diagnosis for the principal diagnosis

Missing criteria and/or submission.

Includes at least 3 differential diagnoses for the principal diagnosis

Includes at least 2 differential diagnoses for the principal diagnosis

Includes at least 1 differential diagnoses for the principal diagnosis

Missing criteria and/or submission.

Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit

Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit

Includes some ICD-10 codes relevant to the diagnoses addressed at the visit

Missing criteria and/or submission.

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required 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.

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the required 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.

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the information:

Missing criteria and/or submission.

Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”

Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”

Includes appropriate diagnostic testing less than 50% of the time.

Missing criteria and/or submission.

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.

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.

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

Missing criteria and/or submission.

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))

Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipator guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))

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))

Missing criteria and/or submission.

Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)

Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)

Missing criteria and/or submission.

Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials

Prescription includes most required components, but is missing 1-2 elements such as quantity to be dispensed or refills

Prescription is missing 3 or more required components such as patient information, date, or provider’s signature

Missing criteria and/or submission.

Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.

Moderately use the literature and other resources to inform their work. Moderately use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.

Ineffectively uses the literature and other resources to inform their work. Ineffectively use of citations and extended referencing. APA style and writing mechanics need serious attention.

Missing criteria and/or submission.