Saint Louis University

SCHOOL OF NURSING

RUBRICS for HEALTH ASSESSMENT

Name of Student: ___________________________
Ward/Hospital: ____________________________

CRITERIA
Comprehensive data
collection ( based on pt.
condition and clinical
setting)
a. History taking
b. Physical
assessment
Systematic performance
of physical assessment
based on clients
condition
(cephalocaudal,
proximo-distal or systems
assessment)
Proper performance of
assessment techniques
0 1 2 3 4
No data gathering of Gross deficiencies in History taking and physical Collects most of the Obtains complete and
pertinent data collection of pertinent assessment is done with pertinent data ( 1 or 2 pertinent health data
data through history collection of some pertinent pertinent data missing) through comprehensive
taking and physical data ( 3 or 4 pertinent data through history taking and history taking and
assessment (more than 4 missing) physical assessment physical assessment
pertinent data missing)
0 1 2 3 4
Performance of Grossly disorganized Disorganized performance Performs assessment in Performs assessment of
physical assessment performance of physical of assessment in 3 most systems/areas all systems/areas
not systematically assessment in 4 systems/areas systematically except for 1- following the correct
done in more than 4 systems/areas 2 system/s interchanged order
systems/areas or skipped
0 1 2 3 4
Incorrect Performs most Performs assessment with 3- With minor errors (1-2 Performs all assessment
performance of all assessment procedures 4 incorrect techniques incorrect technique/s )in techniques correctly
assessment incorrectly and with some extent of the performance of and efficiently
techniques inefficiently ( more than efficiency assessment; displays
4 incorrect techniques) efficiency in assessing

0 1 2 3 4
Accurate reporting of Does not report Fails to report more than Fails to report 3-4 pertinent Fails to report 1-2 Accurately and
assessment findings to the pertinent assessment 4 pertinent assessment assessment findings pertinent assessment comprehensively
findings findings accurately accurately finding/s accurately reports pertinent
CI assessment findings
0 1 2 3 4
Accurate recording of Does not record Recording of assessment Records assessment findings Records assessment Documents all findings
assessment findings in assessment findings data is very inaccurate ( with moderate inaccuracies findings with minimal concisely using
more than 6 errors) and inaccuracies (1-3 error/s)
the assessment tool
 Saint Louis University
SCHOOL OF NURSING
Identifies correct nursing
diagnosis in the correct
format ( 2-part or 3-
part)
Utilize effective
communication skills
(facial expressions,
gestures, touch, distance,
tone of voice, eye contact,
language, and greetings,
proper address and
gratitude after
assessment)
Applies special
considerations (cultural
sensitivity, spiritual
aspects, age and age
appropriate, privacy,
respect for dignity, safety,
consent taking,etc)
Total Score: __________________
Printed Name of CI : ______________________
Date of Evaluation: _______________________
reflects inappropriate ( 4-6 errors) and with some and uses appropriate appropriate
use of terminology appropriate terminology terminology terminology
0 1 2 3 4
No correct nursing Identifies 3 or more Identifies 2 incorrect Identifies 1 incorrect Identifies all nursing
diagnosis identified incorrect nursing nursing diagnosis or 2 nursing diagnosis or 1 diagnosis based on the
diagnosis or 3 or more missing nursing diagnosis missing nursing diagnosis analysis of health data
missing nursing based on health data based on health data gathered correctly
diagnosis based on
health data
0 1 2 3 4
Uses inappropriate Uses inappropriate Uses inappropriate verbal Uses appropriate verbal Uses appropriate verbal
verbal and non- verbal and non-verbal and non-verbal and non-verbal and non-verbal
verbal communication communication techniques communication techniques communication
communication techniques ( more than 4 (3-4 violations) to patient to patient and significant techniques to patient
techniques to patient violations) to patient and and significant others, others with 1 or 2 and significant others
and significant others significant others, rapport is partially violation/s, rapport is all the time, rapport is
all the time; rapport is rapport is not well established established well established
not established established
0 1 2 3 4
Does not apply Minimally applies special Moderately applies special Applies special Consistently applies
special considerations considerations in considerations in considerations in special considerations
in performing performing assessment performing assessment with performing assessment in performing
assessment. with more than 2 2 violations with 1 violation assessment
violations