ob clinical paperwork grading criteria

1

Aquinas College ASN Program

Grading Guidelines Syllabus

Contents:

Labor and Delivery Meds 2 Labor and Delivery Questionnaire 4 Labor and Delivery Article 5 Fetal Heart Rate Monitoring 6 Labor and Delivery Assessment 7 Observation Report 8 Observation Article 9 Postpartum Meds 10 Postpartum Article 12 Postpartum Care Plan 13 Postpartum Teaching 16 Newborn Assessment 21 Newborn Meds 22 Newborn Article 23 Newborn Teaching 24

2

Labor and Delivery Medication Sheet

Student Name _________________________________________________

Cytotec Pregnancy Classification _____/1pt

Drug Classification identified _____/1 pt All routes identified (there should be 3 here) _____/3 pts Specific L/D usage (with dose range and route) cited Induction use PP Hemorrhage use IUFD use _____/9 pts Side Effects _____/2 pts Evaluation _____/4 pts Magnesium Sulfate

Pregnancy Classification _____/1pt Drug classification identified _____/1 pt

Route identified (looking for 2 here) _____/ 2 pts Correct dosage for each use Identification of PTL usage and dose _____/3 pts Identification of PIH usage and dose _____/3 pts Written out _____/2 pts Side Effects _____/2 pts

Evaluation _____/4 pts Oxytocin


All routes identified (should be 2) _____/2 pts Specific use and dosage for L/D Induction Post delivery _____/6 pts Side Effects _____/2 pts

Evaluation _____/4 pts

Terbutaline (ASK THE L&D NURSE!) Pregnancy Classification _____/1pt Drug classification identified _____/1 pt

All routes identified (should be 3) _____/3 pts Specific usage and dosage for L/D cited _____/7 pts Side Effects _____/2 pts Evaluation _____/4 pts

3

Methergine


All routes identified (should be 2) _____/2 pts Specific usage and dosage for L/D cited _____/6 pts Side Effects _____/2 pts

Evaluation _____/4 pts Hemabate


All routes identified _____/1 pt Specific usage and dosage for L/D cited _____/3 pt Side Effects _____/2 pts Evaluation _____/4 pts _____ Additional Deductions for spelling errors, leading or trailing zeroes, etc. (0.5pt each up to 10 points) _____

Total Score _____/100 Graded by______________________________________

Date ______________________________

4

L/D Questionnaire Grading Guide

Student Name ______________________________________

Prenatal Labs _____/24 Labor True Labor _____/3 False Labor _____/3 Tests for ROM _____/3 Wt gain _____/3 Excessive wt gain _____/3 Too little wt gain _____/3 Fluid Blood stained _____/2 Green _____/2 Ruptured >24 hours _____/3 Vaginal Delivery EBL _____/3

C/S EBL _____/3 Stages of Labor 1st _____/4 2nd _____/4 3rd _____/4 G _____/3 T _____/3 P _____/3 A _____/3 L _____/3 EDC _____/2 LMP _____/2 EGA _____/2 Drug Classification System for Pregnancy A _____/2 B _____/2 C _____/2 D _____/2 X _____/2 NR _____/2 Total _____/100

Graded by ____________________________________________

Date ___________________________________________

5

Labor and Delivery Article Grading Rubric

Student Name__________________________________________ Article Selection

5 Appropriate for patient care provided

3 Appropriate for clinical setting but not for care provided

0 Not related to clinical setting or care provided

Nursing Reference

5 Article from a nursing journal

0 Article from a non-nursing journal

Time frame 5 Within designated time-frame (2004-2009)

0 Article not within designated time frame (before 2004)

Reference 5 Referenced and using APA format

3 Referenced but not with APA format

0 No reference

Article Summary

20 Concise summary of article demonstrating clear understanding of content; well written and easy to follow

15 Accurate summary of article, but scattered thoughts and difficult to follow

8 Article not well summarized; reader has poor understanding of article content

0 no summary

Thoughts 10 Good thoughts with opinion given and rationale

5 Random or generic thoughts with no real opinion given of article content or style

0 No summary of thoughts given

Additional Deductions Late Submission (5 pts per day) _____ Spelling or Grammatical Errors (0.5pt per error up to 10 pts) _____

Total Score ____/50 Graded by________________________ Date____________________________

6

Fetal Monitoring Grading Guide

Student Name _______________________________________________

Early Decelerations Description _____/5 Cause _____/10 Treatment _____/10 Variable Decelerations Description _____/5 Cause _____/10 Treatment _____/10 Late Decelerations Description _____/5 Cause _____/10 Treatment _____/10 Variability definition _____/5 Other definitions Absent variability _____/5 Minimal variability _____/5 Moderate variability _____/5 Marked variability _____/5 Total _____/100

Graded by _______________________________________

Date _____________________________________

7

Labor and Delivery Assessment Grading Guide

Student Name ______________________________________ Demographic Data _____/3 Admission V/S _____/2 Prenatal Labs _____/2 History of Labor _____/2 Medications _____/2 Problems Past _____/2 Current _____/2 Vaginal Exam information _____/3 Labor Data _____/3 Stage I _____/2 Stage II _____/2 Delivery data _____/2 Stage III _____/2 Infant Data _____/3 Infant Behavior _____/3 Parental Responses _____/5 Hour by Hour Notes _____/10 Total _____/50

Graded by ______________________________________

Date _______________________________________

8

Observation Report Grading Rubric

Student Name__________________________________________ Article Summary 20

Concise summary of day giving details of experience AND this section is 51-100 words.

10 Concise summary of day giving details of experience AND this section contains only 25-50 words.

5 Accurate summary of day’s events, but scattered thoughts and difficult to follow OR this section contains less than 25 words.

0 no summary

Thoughts 10 Excellent and thoughtful reflection of day’s events and evaluation of them AND this section is 51-100 words.

5 Excellent and thoughtful reflection of day’s events and evaluation of them AND this section is 25-50 words.

3 No evidence of personal reflection on the day’s events OR this section is less than 25 words.


Benefit 10 Thoughtful reflection of benefit of this observation experience AND this section is at least 51-100 words.

5 Thoughtful reflection of benefit of this observation experience AND this section is at least 25-50 words.

3 No evidence of personal reflection of benefit of this observation experience OR this section is less than 25 words.

0 Question not answered

Changes 10 Thoughtful suggestions on how this experience could be changed or not changed to be more beneficial for future students.

5

3

0 Question not answered



9

Observation Article Grading Rubric



3 Appropriate for clinical setting for not for care provided


Nursing Reference







0 No reference

Article Summary




0 no summary






10

Postpartum Medication Sheet

Student Name _______________________________________

Percocet Pregnancy Classification _____/1pt

Drug classification identified _____/1 pt Route identified _____/1 pt

Correct range and frequency of dosage _____/2 pts Indication for use _____/2 pts Specific dosage for patient identified _____/2 pts

Side Effects _____/3 pts Evaluation _____/4 pts

Motrin Pregnancy Classification _____/1pt

Drug classification identified _____/1 pt Route identified _____/1 pt Indication for use _____/2 pts Correct range and frequency of dosage _____/2 pts Specific dosage for patient identified _____/2 pts


Colace Pregnancy Classification _____/1pt

Drug classification identified _____/1 pt Route identified _____/1 pt

Indication for use _____/2 pts Correct range and frequency of dosage _____/2 pts Specific dosage for patient identified _____/2 pts


Rhogam


Route identified _____/1 pt Correct range and frequency of dosage _____/2 pts Indication for use _____/2 pts Specific dosage for patient identified _____/2 pts


Toradol Pregnancy Classification _____/1pt

Drug classification identified _____/1 pt Correct route identified (should be 2) _____/2 pts



11

Ampicillin Pregnancy Classification _____/1pt

Drug classification identified _____/1 pt Correct route identified (should be 2) _____/2 pts



Name _____/3 pts _____ Additional Deductions for spelling errors, leading or trailing zeroes, etc. (0.5pt each up to 10 points) _____

Total Score _____/100 Graded by ______________________________________

Date _________________________

12

Postpartum Article Grading Rubric





Nursing Reference







0 No reference

Article Summary




0 no summary






13

Postpartum Care Plan Grading Rubric Student Name____________________________

Patient History

10 Thorough

history of pt labor/ infant

status

7 A few missing

elements of pt history

(<3)

5 3-6 missing elements

3 > 6 missing elements

0 no patient

history included

Diagnosis #1

10 Appropriate and highest

priority

5 Appropriate Diagnosis but

not accurately prioritized

0 Not a good diagnoses choice for

this patient

Goals 15 Specific and measurable

10 Specific, but

not measurable

7 Too general

0 Not specific

or measurable

Interventions 30 Excellent list

of interventions, considering

specific needs of

individual pt.

25 Good

interventions, but not

considering individual needs of patient

20 Need for > 3

additional interventions

15 Many

appropriate interventions omitted (>5) or 25-50%

interventions listed are not done

10 Good

interventions listed, but >50% not

performed

Rationale 15 Good

explanation of need for

specific intervention

10 25% of

interventions without rationale

7 50% of


5 75% of


0 no rationale

Evaluation 10 Good

evaluation of goals with measurable information

7 Evaluation

accurate, but without

measurable information

5 Interventions not evaluated

in relationship to GOALS

0 No evaluation

14

Postpartum Care Plan Grading Rubric, p. 2 Student Name____________________________

Diagnosis #2


priority




this patient


10 Specific, but

not measurable

7 Too general

0 Not specific

or measurable



specific needs of

individual pt.

25 Good


considering individual need of patient

20 Need for > 3


15 Many



10 Good


performed

Rationale 15 Good



10 25% of


7 50% of


5 75% of


0 no rationale

Evaluation 10 Good


7 Evaluation





0 No evaluation

Comments:

15

Postpartum Care Plan Grading Rubric, p. 3 Student Name____________________________

Diagnosis #2


priority




this patient


10 Specific, but

not measurable

7 Too general

0 Not specific

or measurable



specific needs of

individual pt.

25 Good


considering individual need of patient

20 Need for > 3


15 Many



10 Good


performed

Rationale 15 Good



10 25% of


7 50% of


5 75% of


0 no rationale

Evaluation 10 Good


7 Evaluation





0 No evaluation

Comments:

Total Score____________

Graded by_______________________________________________

Date__________________

16

Postpartum Teaching Grading Rubric Student Name Pain Management

Teaching

4 Thorough Information included; Easy to read and follow.

2 Good amount of information; scattered and not well organized.

1 Fair amount of information; scattered and not well organized.

0 No submission.

Rationale

1 Thorough and good rationale

0 No rationale given

Sources 1 Sources listed

0 Sources not listed

Presentation 4 Presentation given with little reading. No information added by instructor during presentation

3 A good amount of reading or little information added by instructor during teaching session.

2 A good amount of reading and/or lots of information added by instructor during session

1 Mostly read and/or lots of information added by instructor during teaching session.

0 Not prepared for presentation on day assigned.

Comments: Vaginal Discharge

Teaching




0 No submission.

Rationale










Comments:

17

Pericare/Hygiene/Bathing Teaching




0 No submission.

Rationale










Comments: Elimination Teaching




0 No submission.

Rationale










Comments:

18

Diet/Exercise Teaching




0 No submission.

Rationale










Comments: Breast Care Teaching




0 No submission.

Rationale










Comments:

19

Emotional Changes

Teaching




0 No submission.

Rationale










Comments: Sexuality/Family Planning

Teaching




0 No submission.

Rationale










Comments:

20

C/S Incision Care

Teaching




0 No submission.

Rationale










Comments: (*Note to Clinical Instructor: If student is teaching a Vaginal Delivery patient, please give full 4 points here for presntation) When to call doctor

Teaching




0 No submission.

Rationale










Comments: Additional deductions for spelling and grammatical errors (0.5pts each up to 10 pts) ____________

Total Score _______/ 100 Graded by_________________________________ Date_________________

21

NEWBORN ASSESSMENT Grading Guide

Student Name __________________________________________________

Normal Findings and Common Variations _____/100 Be detailed and give all possible findings Deductions will be 0.5 pt for each identified piece of missing information or lack of specificity in information Assessment of Your Baby _____/100 Be specific Deductions will be 1 pt for each identified piece of missing information or lack of specificity in information Teaching needs Related to Normal Newborn Clients _____/50 What might the parents need to be told regarding care of their infant based on possible and actual assessment findings? Deductions will be 0.5pt for each identified piece of missing information or lack of specificity in information Total _____/250 Date_________________________________________________________ Graded by_____________________________________________________

22

Newborn Nursery Medication Sheet

Student Name __________________________________________ EES ophthalmic ointment Drug classification identified _____/1 pt Route identified _____/2 pts Correct dosage range and frequency identified _____/3 pts Identification of use _____/3 pts Specific dosage for patient identified _____/3 pts Side Effects _____/3 pts Evaluation _____/5 pts Vitamin K

Drug classification identified _____/1 pt Route identified _____/2 pts

Correct dosage range and frequency identified _____/3 pts Identification of use _____/3 pts Specific dosage for patient identified _____/3 pts Side Effects _____/3 pts Evaluation _____/5 pts Hepatitis B


Correct dosage range and frequency identified _____/3 pts Identification of use _____/3 pts Specific dosage for patient identified _____/3 pts Side Effects _____/3 pts Evaluation _____/5 pts Sucrose


Correct dosage range and frequency identified _____/3 pts Identification of use _____/3 pts Specific dosage for patient identified _____/3 pts Side Effects _____/3 pts Evaluation _____/5 pts EMLA Cream


Correct dosage range and frequency identified _____/3 pts Identification of use _____/3 pts Specific dosage for patient identified _____/3 pts Side Effects _____/3 pts Evaluation _____/5 pts _____ Addition Deductions for spelling errors, leading or trailing zeroes, etc. (0.5pt each up to 10 points) _______

Total Score _____/100

Graded by __________________________________________

Date ______________________________________

23

Nursery Article Grading Rubric





Nursing Reference


0 Article from a nonnursing journal





0 No reference

Article Summary




0 no summary






24

Newborn Teaching Grading Rubric Student Name Bulb Syringe Teaching 5

Thorough Information presented without reading; No need for instructor to add additional information

4 Thorough, but information mostly read to client; no need for instructor to add additional information

3 Good information given and presented without reading; Necessary for instructor to add little information

2 Good information given but information mostly read to client; little information added by instructor

1 Weak on amount of information presented to client with little reading; Instructor added a good amount of additional information

0 Weak on amount of information presented to client and mostly read to client.

Rationale





Written documentation

2 Information added by instructor during teaching session included in documentation

1 Some information added by instructor during teaching session included in documentation

0 No information added by instructor during teaching session included in documentation

Comments: Positioning Baby

Teaching 5 Thorough Information presented without reading; No need for instructor to add additional information






Rationale









Comments:

25

Bottle Feeding Teaching 5







Rationale









Comments: Breast Feeding







Rationale









Comments:

26

Elimination Teaching 5







Rationale









Comments: Bathing/Skin Care







Rationale









Comments:

27

Cord Care Teaching 5







Rationale









Comments: Circumcision Care







Rationale









Comments:

28

Thermometer Use







Rationale









Comments: Jaundice Teaching 5







Rationale









Comments:

29

When to Call MD







Rationale









Comments:

Name included _____/1 Total Score _______/ 100 Graded by_________________________________ Date______________

ob clinical paperwork grading criteria

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