1
Medical Chart Review Grading Rubric
Instructions: Provide the requested information for each Case provided for the assignment. Identify the Cases by number, such as Case 6. Utilize guidelines found in
MindTap – Essentials of HIM by Bowie, Chapter 6 and other web-based resources.
1) Face Sheet/Admitting Information- Identify areas of non-compliance with the Chart Analysis Guidelines
Low Mastery Proficient Mastery Competent Mastery High Mastery
a) Provide the admission and discharge date.
b) Calculate the length of stay.
c) State the name of the admitting
physician.
d) Name the service to which the
patient was admitted
e) Provide the admit type.
a) Fulfill requirements of Low Mastery.
b) Provide the admitting diagnosis.
c) Provide the principal diagnosis.
d) List the secondary diagnoses if
documented on the face sheet.
e) Provide the primary insurer for the
patient.
a) Fulfill requirements of Low and
Proficient Mastery.
b) Provide the name of the individual
who signed the consent to admit and
the relationship to the patient if
applicable.
c) Specify if an advanced directive
was completed and who signed the
document.
a) Fulfill requirements of Low,
Proficient and Competent Mastery.
b) Specify when the Consent to
Release Information for
Reimbursement Purposes expires.
c) Other than for reimbursement, what
else does the Consent to Release
Information for Reimbursement
cover?
2) History and Physical/Consultation Report- Identify documentation found in the H&P or Consultation Report
Low Mastery Proficient Mastery Competent Mastery High Mastery
a) Provide the date and time that the history
and physical was dictated and typed.
b) State the chief complaint.
c) Identify where the chief complaint was
documented in the record. Be specific; there
may be more than one place to find the chief
complaint.
d) Does the H&P meet the timeframe
specified in the Chart Analysis Guidelines?
e) Provide the treatment plan for the patient.
Be specific including medications, diagnostic
or therapeutic procedures and where the
patient was admitted. Document as written in
the record.
a) Fulfill requirements of Low Mastery.
b) Specify the consulting physician’s
name if a consultation was done.
c) Specify the problem(s) the
consultant was asked an opinion, if a
consultation was done.
d) Summarize the details of the history
of present illness.
e) Compile relevant social and family
history.
f) Specify documentation in the review
of systems.
g) Identify where d, e, and f were
found in the record.
a) Fulfill requirements of Low and
Proficient Mastery.
b) Record the patient’s vital signs—
temperature, pulse, respirations,
blood pressure
c) Infant record- provide the actual
weight, birth weight, height and age
of patient at time of admission.
d) Specify the abnormal findings
noted in the physical examination.
a) Fulfill requirements of Low,
Proficient and Competent Mastery.
b) Compare/contrast the admitting
diagnosis, principal diagnosis, chief
complaint and provisional/impression
diagnosis.
In your opinion, are the diagnoses
essentially the same? If not, how are
they different.
2
3) Progress Notes- Identify if each progress note is legible, signed, dated and timed in accordance with the Guidelines.
Differentiate between progress notes and physician orders. Demonstrate an understanding of the purpose of progress notes.
Low Mastery Proficient Mastery Competent Mastery High Mastery
a) List the disciplines that have
written in the progress notes such
as respiratory therapy.
b) Specify what the professional
credential following the
care giver’s name represents
such as MD Is medical doctor,
RN is registered
Nurse.
c) Provide the date of each
progress note missing any of the
following-signature, credentials
of the individual writing the
progress note, or time.
d) Provide the date of the
progress note(s) you find
illegible.
a) Fulfill requirements of Low
Mastery.
b) Describe the type of
information found in the progress
notes such as vital signs.
c) State in your own words, the
purpose of progress notes.
a) Fulfill requirements of Low and
Proficient Mastery.
b) Perform the following:
Case 6- Read progress note 4/29.
Type the progress note as stated.
Case 10- Read progress note
4/26 at 2200. Type the progress
note as stated.
a) Fulfill requirements of Low,
Proficient and Competent Mastery
b) Prepare a bulleted list of
concerns and recommendations
you have based upon your
review of the progress notes in
these records. This list would be
written at the level to present at a
quality of documentation meeting.
3
4) Physician Orders-Identify if each physician order is legible, signed, dated and timed in accordance with the Guidelines.
Low Mastery Proficient Mastery Competent Mastery High Mastery
For each case:
a) Specify the case number
b) Itemize what (if anything) has
been omitted from the physician
orders (time, date, signature).
*If nothing is identified, the
assumption is that the orders
meet the Guidelines.
c) Indicate if each verbal or
telephone order is signed by
the physician.
d) Specify the date of the verbal
or telephone orders not signed.
a) Fulfill requirements of Low
Mastery.
b) Look at the first day’s
admission orders for each case and
provide the following:
Case 06- 1) Name three
medications ordered, 2) Name three
laboratory tests ordered,
3) Name two diagnostic services
ordered. 4) Is there a corresponding
report for each laboratory or
diagnostic test you identified? List
exceptions.
Case 10- 1) Name three laboratory
tests ordered. 2) State how the
oxygen was to be administered to
the patient. 3) Is there a
corresponding report for each
laboratory test you identified? List
exceptions.
a) Fulfill requirements of Low and
Proficient Mastery.
b) Case 10- Refer to orders 4/26 at
1630 and 4/29 at 0150. What does
R.A.V. mean in front of the
signatures?
a) Fulfill requirements of Low,
Proficient and Competent Mastery
b) Select the one case you believe
best exemplifies good adherence
to the Guidelines provided for
Doctors Orders. Explain why.
c) Select the one case you believe
falls short in adherence to the
Guidelines provided for Doctors
Orders. Explain why.
Overall Mastery Rating: Low Proficient Competent High
Updated: 7.23.2017
Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?
Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.
Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.
Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.
Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!
While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.
Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.
In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.
Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.
We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!
We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.
Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.
We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.
Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.
There is a very low likelihood that you won’t like the paper.
Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.
We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.
You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.
We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.
You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
GET A PERFECT SCORE!!! 
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Read moreEach paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Read moreThanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.
Read moreYour email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.
Read moreBy sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.
Read more