Capp Case Reflection Scoring Rubric

CAPP CASE REFLECTION SCORING RUBRIC

Title of Case: CAPP Pelvic or OB: Date Submitted: Submission – Initial or Revision: Date of PF3 or OB-Advanced: Case Number: Reviewer Code: Date Reviewed:

____ Pass – Satisfactory; meets expectations ____ Resubmit Required to Pass – Please revise items in the case that are marked in the “NO” column

Each section must PASS in order to achieve a PASS for the entire Case Reflection.  For a section to “PASS,” each component of the section must be clearly covered and checked off by the reviewer as being present and complete.  *If these items in the “Case Organization and Presentation” do not pass, the case will automatically be returned for revision prior to a full review being completed, as the presence of these elements contribute to readability and overall completeness of the case.

Case Organization and Presentation YES N O *All required sections are present (Introduction, Examination, Evaluation/Diagnosis, Prognosis/Plan of Care, Intervention, Outcome, Case Reflection), and occur in the same order they appear in the scoring rubric *The case is written in full sentence and paragraph formation; shorthand or incomplete sentences are not used to describe the case *There are few, if any, errors in syntax, grammar, spelling, tense use, and/or punctuation De-identification was performed to safeguard the patient’s identity References are listed in the order in which they are cited in the case References are provided in AMA or APA format Appropriate references are cited to support information in the introduction and all sections of the paper (except for history and desired outcomes) References are recent within the last 10 years unless a seminal or empirical study, or unless they are the most recent available literature in support of the cited statement SECTION PASSES? Comments related to items marked with “NO”: 

INTRODUCTION YES N O Explains why this patient was selected for the case reflection: How does this patient fit into specialized pelvic (CAPP-Pelvic) or OB (CAPP-OB) practice? Includes background information pertaining to current medical evaluation and treatment of given diagnosis/patient type Provides relevant history, including demographic characteristics and pertinent psychological, social, and environmental factors Includes comorbidities Medical differential diagnoses: Relates to patient history and symptoms; discusses possible medical diagnoses that could be causing patient symptoms and how therapist will screen and/or what medical testing would rule (or has already ruled) these out Musculoskeletal differential diagnoses: Explains the potential musculoskeletal / physical therapy diagnoses that could be causing symptoms, and how these can be differentiated Describes the patient’s desired outcomes SECTION PASSES? Comments related to items marked with “NO”: 

EXAMINATION YES N O Explains functional outcome tools selected, including rationale for choosing Provides information on validity, specificity, sensitivity, and/or likelihood ratio of outcome tool, if available; or reports if these pieces of information are not available Clearly explains the rationale for using selected tests and measures with appropriate references to support the rationale Clearly explains all examination data, including what information the results are validated to provide Explains special tests utilized, what constitutes a +/- result, and provides results for this patient SECTION PASSES? Comments related to items marked with “NO”: 

EVALUATION / DIAGNOSIS YES N O Provides summary of findings, including functional limitations Relates findings back to differential diagnoses, supporting selected physical therapy diagnosis Provides physical therapy diagnoses SECTION PASSES? Comments related to items marked with “NO”: 

PROGNOSIS / PLAN OF CARE YES N O Provides a list of patient-centered, functional goals that are objective, measurable and occur in a specific time period Provides prognosis for patient to achieve established goals, including rationale from available supportive literature regarding potential outcome Describes plan of care SECTION PASSES? Comments related to items marked with “NO”: 

INTERVENTION YES N O Clearly explains rationale for each intervention that is chosen Explains intervention so clearly and thoroughly that another clinician could replicate (e.g., instructions and cueing given to patient, repetitions and sets for exercises or activities, positioning of interventions/exercises, etc.) Clearly explains the amount of intervention provided (frequency, duration, patient adherence, and barriers encountered) Clearly explains the chronology of interventions and changes in treatment over time Clearly explains the rationale for changes that are made to the intervention over time SECTION PASSES? Comments related to items marked with “NO”: 

OUTCOMES YES N O Compares measured outcomes with the patient’s initial status, and explains what the changes in measurements indicate Indicates outcome of each established physical therapy goal Describes progress made toward the patient’s desired outcomes; includes discussion if outcomes not fully achieved SECTION PASSES? Comments related to items marked with “NO”: 

CASE REFLECTION YES N O Reflects on the case, and describes what the clinician would do differently next time Describes if barriers were present and their impact on treatment Describes lessons learned and/or questions that have arisen as a result of this case study SECTION PASSES? Comments related to items marked with “NO”: 

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