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iRubric: Soap Note Grading Rubric
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Soap Note Grading Rubric
Rubric designed to evaluate soap notes by graduate nursing students
Rubric Code:
B5XA95
By
carolynn1
Draft
Private Rubric
Subject:
Medical
Type:
Assignment
Grade Levels:
Graduate
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Soap Note Grading Rubric
Below Average
1 pts
Average
2 pts
Above Average
3 pts
Exceptional
4 pts
Documentation is clear and well org
Below Average
Documentation does not meet expectations for the graduate level as evidenced by either of the following:
lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Average
Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for SOAP documentation.
Narratives such as the HPI and Exam occasionally stray from logical sequence but the reader is able to determine findings with minimal difficulty.
Above Average
Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for SOAP documentation.
Exceptional
Documentation is clear and well organized.
Appropriate medical terminology is used.
Redundant (repetitious) words, phrases, and other distracting information are omitted.
Format follows a standard. Narratives such as the HPI and Exam have a logical flow.
Subjective assessment is fully expl
Below Average
Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment
Average
Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.
Above Average
Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.
Exceptional
Subjective assessment of health status is fully explicated
CC and HPI are targeted toward the reason for presentation without the inclusion of extraneous information.
CC is succinct.
HPI is fully developed and includes location, duration, timing, character, severity provocative/palliative factors and/or other features appropriate for the reason for presentation.
Elements of the PMH, FH, and ROS that expand on the CC and HPI are included.
Objective assessment is fully expli
Below Average
Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/or inappropriate for the presenting problem.
Average
Two or more elements needed for adequate evaluation of a patient's problem is missing from the subjective and/or objective assessment.
Selection of diagnostic tests is inappropriate for CC or is missing when needed.
Above Average
Objective assessment is missing an element needed for adequate evaluation of the patient's problem.
Includes irrelevant information
Selection of diagnostic tests is too broad or expensive for evaluating the presenting problem OR
Selection of diagnostic tests is inadequate to address the presenting problem
Exceptional
Objective assessment of health status is fully explicated
Physical exam includes vital signs, height and weight for all children and for others as appropriate, and any relevant developmental data related to assessment of CC.
Appropriate diagnostic tests are performed/ordered.
Diagnoses are adequate, coherent, a
Below Average
Lacks differential diagnoses and/or final diagnosis is inappropriate or unacceptable for subjective and objective assessment
Average
Limited differential diagnoses considered and/or final diagnoses only minimally applicable for subjective and objective assessment
Above Average
Minimum of 5 differential diagnoses considered and appropriate final diagnoses selected for subjective and objective assessment
Exceptional
Greater than 5 appropriate differential diagnoses considered and evidence that final diagnoses was determined utilizing evidence-based research as applied to subjective and objective assessments
Plan is coherent, complete, and afi
Below Average
Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up.
Average
Management plan is appropriate but inadequate to fully address the identified problem.expansive or overwhelming for the client or healthcare system OR
Needs to consider alternative features for optimal outcomes
Above Average
Management plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.
Exceptional
Management plan is appropriate for the diagnosis and accurately addresses the problem identified.
Management plan is economically sound.
Management plan includes plans for evaluation/follow-up care (as appropriate).
Management plan is individualized to the patient's age and development, culture, religion, family, environment, education, and/or any other unique concerns uncovered in assessment.
Evidence-based guidelines utilized
Below Average
Two or more references are from consumer, non-professional, or non-authoritative websites or magazines, or are not-peer reviewed or are less than the required three minimum.
Average
Relies on nursing journal articles that are not "scholarly" and/or are written for nurses not in advanced practice
Above Average
Authoritative and peer-reviewed references are used to guide decisions regarding diagnosis and treatment. Some research articles and references are greater than three years old but less than five years old.
Exceptional
Authoritative and peer-reviewed references are used to guide decisions regarding diagnosis and treatment. All research articles and references are less than three years old.
Subjects:
Medical
Types:
Assignment
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