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iRubric: Documentation Review Mentoring Form rubric

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Documentation Review Mentoring Form Derived from form provided by University of Chicago Medical Center Rubric Code: U4B79 By teachme Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: Graduate, Post Graduate

Documentation Review Mentoring Descriptions 100 %
	Incomplete 0 pts	Needs Assist 1 pts	Independent 2 pts
Documentation: is documentation complete, addresses reason for need for skilled intervention, appropriate flowsheets completed. Orders completed (if indicated)	Incomplete	Needs Assist	Independent
Data Gathering/Medical Screening: appropriate review of patient’s medical record to ensure appropriate referral, admission dx, lab values, vitals, medical devices, appropriateness for therapy intervention, etc.	Incomplete	Needs Assist	Independent
Prioritization/POC: able to identify priority status and appropriate plan of care per IP pathway algorithm, deviations from pathway explained	Incomplete	Needs Assist	Independent
D/C Planning: appropriate d/c recommendation made, articulates rationale, communicated to patient and team, etc	Incomplete	Needs Assist	Independent
Goal Setting: goals are measurable, appropriate for pt current functional level and anticipated length of stay.	Incomplete	Needs Assist	Independent
Updating Plan of Care: if indicated d/t change in medical status or need for re-evaluation d/t length of stay.	Incomplete	Needs Assist	Independent
Time Spent 0 %
	30 Minutes (N/A)	45 Minutes (N/A)	1 Hour (N/A)
Enter actual time in notes	30 Minutes Enter actual time in notes	45 Minutes Enter actual time in notes	1 Hour Enter actual time in notes
Patient Location 0 %
	N/A (N/A)	ICU (N/A)	Floor (N/A)
Select ICU or Floor	N/A	ICU	Floor
Patient Complexity 0 %
	Low (N/A)	Medium (N/A)	High (N/A)
Make a Selection	Low	Medium	High