CAPP CASE REFLECTION SCORING RUBRIC
APTA SoWH
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 your 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 / NO
*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 done 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 (American Medical Association) format
Appropriate references are cited to support introduction information (except for history and desired outcomes), examination section items, determination of physical therapy diagnosis, prognosis, and rationale for interventions.
References are from 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 / NO
Explains why this patient was selected for the case report: 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: Related to patient history and reported symptoms, discusses possible medical diagnoses that could be causing patient symptoms and how therapist will screen for these and what medical testing would rule (or has already ruled) these out
Musculoskeletal differential diagnoses: What are the potential musculoskeletal / physical therapy diagnoses that could be causing symptoms, and how can these be differentiated?
Describes the patient’s desired outcomes
SECTION PASSES?
Comments related to items marked with “NO”:
EXAMINATION
YES / NO
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 reporting if these pieces of information are not available
Clearly explains the rationale for using 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 / NO
Provides summary of findings, including functional limitations
Relates findings back to differential diagnoses, supporting selected physical therapy diagnosis
Provides physical therapy diagnoses
Provides practice pattern(s) as per Guide to Physical Therapy Practice
SECTION PASSES?
Comments related to items marked with “NO”:
PROGNOSIS / PLAN OF CARE
YES / NO
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 / NO
Clearly explains rationale for each intervention that is chosen
Explains intervention so clearly and thoroughly that another clinician could replicate (e.g., instructions given to patient, repetitions and sets for exercises or other activities, positioning of interventions/exercises, etc.)
Clearly explains the amount of intervention provided (ie 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 / NO
Compares measured outcomes with the patient’s initial status, and explains what the changes in measurement means
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 / NO
Provides a reflection of the case: discuss 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”:
Comments: