DOCUMENTATION RUBRIC

Make    sure    to    include:    
BRIEF OVERVIEW
- Age, sex, chief complaint
- Relevant symptoms and history
- Abnormal vitals
- Complete in 1-2 sentences
TESTING
- Rationale for ordering
- Address any abnormal results
- Why no further testing is needed
THERAPY
- Rationale for treatment
- Response to therapy
INITIAL DIFFERENTIAL
- Differential based on brief overview
- What can be ruled out based on H&P
- Minimum 3 diagnoses
INITIAL TESTING
- Rationale for tests ordered
INITIAL THERAPY
- Rationale for treatment
UP    TO    DATE    DIFFERENTIAL
- Minimum 3 emergency diagnoses
- Diagnoses that are ruled in/out
- Conclusion based on results
- Common complications
DISCREPANCIES
- Nursing and EMS documentation
- Negative points only
AFTER CARE
- Treatment plan
- Follow-up
- Return Precautions
- Timeline
FINAL THERAPY
- Response to therapy
FINAL TESTING
- Address any abnormal results
- Why no further testing is needed

FINAL DIFFERENTIAL
- Conclusion based on testing and why
- What the diagnosis is not, and why
- Common complications