Skip to main content
iRubric: SOAP Note Rubric

iRubric: SOAP Note Rubric

find rubric

(draft) edit   print   share   Copy to my rubrics   Bookmark   test run   assess...   delete   Do more...
SOAP Note Rubric 
SOAP Note Rubric
Rubric to grade a PTA SOAP note
Rubric Code: Q6CXX7
By historytchr
Draft
Public Rubric
Subject: Health  
Type: Writing  
Grade Levels: (none)

Powered by iRubric SOAP Note Rubric
  Fail (0-6)

(N/A)

Good (7 -8)

(N/A)

Excellent (9-10)

(N/A)

Patient and injury information
1 %

Fail (0-6)

Gives no information
Good (7 -8)

Gives irrelavant information about the patient or does not include appropriate personal information.
Excellent (9-10)

Includes all pertinent patient information at the top of the page including patient name, insurance information, date of birth and gender of the patient. The information about the injury includes evaluation date, date of injury, first visit date, and diagnosis of the patient.
Subjective
5 %

History of Patient Illness
Fail (0-6)

Gives no information
Good (7 -8)

Gives small amount of pertinent information or incomplete ideas of the patient.
Excellent (9-10)

Provides Chief complaint, any current medications, symptoms, and activities of daily living. This information reflects the true feelings of the patient.
Enter Title
1 %

Fail (0-6)
Good (7 -8)
Excellent (9-10)
Objective
40 %

The section needs to include:
1. Length of time, where, and for what the client was seen.
2. Report WHAT YOU SEE (chronologically or by categories)
3. Deemphasize the media. Leave yourself out, Focus on the client's response, do not be judgmental, specify when and how much assistance was needed, show skilled OT happening
Response to patient or caregiver's education.
Fail (0-6)

Not objective
No skill OT reflected
Client is judged
You write what YOU did.
Poor grammar and spelling.
Messy, not professional looking
Good (7 -8)

Do not include measurable skills worked on
Fair grammar and spelling, therefore although errors are present, note is understandable
Excellent (9-10)

All elements present. Excellent grammar, spelling. Very professional
Assessment
40 %

Go into each data of the objective section, asking yourself what problems, progress, and rehab problems do you see.
So what?... Why is this important to the client. Anything that is less than WFL's should be addressed regarding impact on client's performance areas.
Include education areas.
End with: CLIENT WILL BENEFIT FROM SKILLED OT SERVICES IN ORDER TO .....
Goals may be included (according to some authors)
Fail (0-6)

Elements present in the objective section not discussed or new elements discussed which were not mentioned in the Objective.
Goals do not meet ABCDE criteria
Poor grammar and spelling.
Messy, not professional looking
Good (7 -8)

No justification for continued OT or no mention of why client is been discharged.
Fair grammar and spelling, therefore although errors are present, note is understandable
Excellent (9-10)

All elements present. Excellent grammar, spelling. Very professional
Plan
15 %

How often will the client be seen and for how long.
What are you going to be working on, or if client will be discharged.
Goals may be included (according to some authors)
Fail (0-6)

Missing two or more elements element
Goals do not meet ABCDE criteria
Good (7 -8)

Missing one element.
Fair grammar and spelling, therefore although errors are present, note is understandable
Excellent (9-10)

All elements present. Excellent grammar, spelling. Very professional
Enter Title
1 %

Fail (0-6)
Good (7 -8)
Excellent (9-10)

Uses proper headings and sub-headings. Overall product is easy to read and well organized.



Keywords:
  • SOAP note, medical documentation

Subjects:

Types:

Discuss this rubric




Do more with this rubric:
Preview

Preview

Preview this rubric.
Edit

Edit

Modify this rubric.
Copy

Copy

Make a copy of this rubric and begin editing the copy.

Print

Print

Show a printable version of this rubric.
Categorize

Categorize

Add this rubric to multiple categories.
Bookmark

Bookmark

Bookmark this rubric for future reference.
Assess
This rubric is still in draft mode and cannot be scored. Please change the rubric status to ready to use.
Share
Publish

Publish

Link, embed, and showcase your rubrics on your website.
Email

Email

Email this rubric to a friend.
Discuss

Discuss

Discuss this rubric with other members.
 

Do more with rubrics than ever imagined possible.

Only with iRubrictm.


Copyright © 2024 Reazon Systems, Inc.  All rights reserved.
n60