DCE Health History Rubric

CRITERION	PROFICIENT (5 points)	DEVELOPING (4 points)	BEGINNING (3 points)
Subjective Data Collection	Identifies multiple strengths in subjective data collection. Acknowledges where improvements could be made. Gives appropriate examples of correct subjective data collection and areas needing development in the collection of subjective data. Gives clear reflection of what was done well and what areas should be improved. Shows excellent insight into the performance of subjective data collection.	Has strengths and areas needing development identified. Gives appropriate examples of correct subjective data collection and areas needing development in the collection of subjective data. Reflection is appropriate although insight may be superficial or shallow.	Has strengths and areas needing development identified but may not be entirely correct with what is labeled as a strength. Gives examples of correct subjective data collection and areas needing development in the collection of subjective data although these may not be accurate. Begins the reflection into subjective data collection but does not give a complete picture or presents a skewed picture of what the issues in data collection were.
Therapeutic Communication	Has multiple indicators that confirm that therapeutic communication was utilized throughout the health history. Has extensive identification of the times when conversation was not therapeutic and gives examples of how communication could have been improved. Insight is profound about performance in therapeutic communication.	Indicates when and how therapeutic communication was utilized throughout the health history. Identifies conversation that was not therapeutic. Reflection is appropriate although insight into how communication might be improved is superficial.	Reflects on therapeutic versus non-therapeutic communication without extensive insight into methods of improvement.
Information Processing	Identifies how information was processed that led to further questioning of the patient. Able to identify areas in which information was missed due to the lack of processing of information being provided by the patient. In-depth analysis provided regarding strengths and weaknesses in this area.	Indicates when appropriate processing of information occurred and when information was missed. Reflection is appropriate although insight into what would improve the processing is superficial.	Reflects on information processing and able to provide a basic understanding of when appropriate processing occurred and when information was missed. Superficial evaluation provided for the processing of the patient information.
Organization/Systematic Approach	Provides an in-depth analysis of the organization and systematic approach that was utilized during the health history. Identifies where improvements could be implemented in the process.	Reflects on the positive and negative aspects of organization during the health history. Analysis is appropriate but brief.	Identifies the organization and systematic approach that was utilized but does not recognize where improvements might need to occur or provides inappropriate reflections on areas needing improvement.
Documentation	Identifies strengths and gaps in documentation. Makes appropriate distinctions between the documentation that is clear and complete and the documentation that needs improvement Analysis is appropriate and extensive.	Identifies strengths and gaps in documentation. Could be more thorough in analysis. Gives superficial overview of documentation that needs improvement.	Reflects on strengths and gaps in documentation but may not be accurate in discriminating between a strength and a gap. Has minimal analysis.
DCE Score	DCE score 90-100% of national norm on this assessment.	DCE score 80-89% of national norm on this assessment.	DCE score 70-79% of national norm on this assessment.

7-26-18 PW

There are 30 points possible for this reflection on the health history of the patient.