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iRubric: SOAP Note Rubric
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SOAP Note Rubric
SOAP Note Rubric
Rubric for SOAP Notes for PA Students
Rubric Code:
SX6B623
By
nefpanuelos
Ready to use
Public Rubric
Subject:
Medical
Type:
Assignment
Grade Levels:
Graduate
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Soap Note Grading Rubric
Unacceptable
1 pts
Below Average
2 pts
Average
3 pts
Above Average
4 pts
Exceptional
5 pts
Subjective
Unacceptable
Subjective assessment is missing 4 or more critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment
Below Average
Subjective assessment is missing 3 or more critical elements needed for adequate evaluation of the patient's problem.
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
Unacceptable
Objective assessment is not developed AND the assessment is inappropriate for the patient's age, gender, AND inappropriate for the presenting problem.
Below Average
Objective assessment is not developed OR the assessment is inappropriate for the patient's age, gender, 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.
Assessment
Unacceptable
Assessment is inappropriate or unacceptable based on subjective AND objective data
Below Average
Assessment is inappropriate or unacceptable based on subjective OR objective data
Average
Assessment is limited and only minimally applicable to subjective and objective data. Missing information, shows basic understanding of patients condition
Above Average
Adequate assessment of the patient. Demonstrates an underatanding of the disease states, may be missing minor information that does not affect the overall assessment.
Exceptional
Thorough assessment of the patient. Shows clear understanding of the patients disease states and current conditions.
Plan
Unacceptable
Plan is inappropriate, lacking essential components related to final diagnoses, AND neglects patient education and follow-up.
Below Average
Plan is inappropriate, lacking essential components related to final diagnoses, OR neglects patient education and follow-up.
Average
Plan is 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
Plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.
Exceptional
Plan is appropriate for the diagnosis and accurately addresses the problem identified.
Plan is economically sound.
Plan includes plans for evaluation/follow-up care (as appropriate).
Plan is individualized to the patient's age and development, culture, religion, family, environment, education, and/or any other unique concerns uncovered in assessment.
Documentation
Unacceptable
Documentation does not meet expectations for the P2 level as evidenced by either of the following:
lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Below Average
Documentation does not meet expectations for the P2 level as evidenced by either of the following:
lay terminology, illogical sequencing, and/or missing essential elements.
Average
Documentation needs to be more 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.
Subjects:
Medical
Pharmacy
Types:
Assignment
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