iRubric: Medical SOAP Note rubric

3+ mechanical errors (e.g. spelling, syntax, punctuation); Inconcise reporting; Irrelevant report of information that does not impact performance; Overuse of simplified language; Repetitive errors; redundant statements across 3+ consecutive SOAPs.

1-3 mechanical errors; Simple language distinctively tied to client/family reporting; Partial reporting integrated with performance discussion; redundant statements across 2 consecutive SOAPs.

Brief and concise statements; All reports are distinctively related to performance; No mechanical errors; No redundant statements between SOAP submissions.

Inconsistent and incohesive reporting from 'S' and 'O' statements; No mention of skilled services the pt. received; Minimal evidence of cohesive language (3+); Overuse of simplified language; 3+ missed opportunities for professional terminology; 2+ statements of materials used with limited to absent discussion of clinical implications; Irrelevant use of examples for 1+ target objective; No report of functionality of tx; 3+ mechanical errors; Repetitive errors following peer review.

Missing comparative data; 2-3 instances of improper use of professional terms; Incorrect or incomplete mention of skilled services the pt. received; Moderate evidence of cohesive language; Incorrect or incomplete report of functionality of treatment; Discussion of clinical implications throughout 1/2+ of the reporting; Vague reporting of client response to intervention.

Clinical implications discussed via conclusions and professional judgment; 1 inappropriate use of professional language; Clear, analytical discussion of client response to intervention; Consistent reporting of comparative data across performance; Reported information follows a logical sequence; Concise reporting with ALL relevant qualitative and quantitative information; Correctly mentioned skilled services the pt. received; Correctly and professionally reported functionality of tx