Medical Chart Review Grading Rubric

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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.
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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.
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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