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SOAP Rubric
Rubric Code:
W3C5A3
By
kkomurek
Ready to use
Public Rubric
Subject:
Health
Type:
Assignment
Grade Levels:
Undergraduate
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Patient SOAP
Excellent
6 pts
Good
4 pts
Fair
2 pts
Poor
0 pts
Subjective Findings
Excellent
Patient’s overall appearance and demeanor is listed here and is an accurate representation. There is no objective information noted in this section.
Good
Patient’s overall appearance and demeanor is listed here and is an accurate representation. Objective information is noted in the section.
Fair
The subjective findings are not an accurate representation of the patient’s overall appearance and demeanor. Objective information is noted in this section
Poor
Left blank
Objective Findings
Excellent
All physical exam findings, body weight, urine/fecal notes, incision appearance, pain scores are noted here.
Good
One to two pieces of objective information is missing in this section.
Fair
More than two pieces of objective information are missing in this section.
Poor
Left blank
Assessment
Excellent
Entry clearly states assessment of general physical status, status for surgery, recovery from anesthesia and surgery, health of incision, effectiveness of pain management
Good
One to two pieces of the assessment is missing in this section.
Fair
More than two pieces of the assessment are missing in this section.
Poor
Left blank
Plan
Excellent
Plan includes future diagnostics, surgery, treatment, discharge information. Entry clearly lists all appropriate actions for the patient while hospitalized
Good
One to two pieces of the plan is missing in this section.
Fair
More than two pieces of the plan is missing in this section.
Poor
Left blank
Terminology
Excellent
Medical terminology is correctly used and spelled throughout entry. Correct medical abbreviations are used throughout entry. Units of measurement are consistently used
Good
Medical terminology is correctly used and spelled throughout most of entry. Spelling mistakes are minor. Correct medical abbreviations are mostly used throughout entry. Units of measurement are inconsistently used
Fair
Medical terminology is frequently incorrectly used and misspelled. Medical abbreviations are incorrect. Units of measurement are frequently missing or used incorrectly
Poor
Left blank
Technical
Excellent
Hand writing is neat and legible. Medical record is written in pen. Patient information is complete at top of page. Entry is dated, timed and signed.
Good
Hand writing is mostly legible. Medical record is written in pen. Patient information is complete at top of page. Entry is missing 1 of the following: date, time, signature
Fair
Hand writing is illegible. Medical record is written in pen. Patient information is incomplete at top of page. Entry is missing 2 of the following: date, time, signature
Poor
Medical record is written in pencil. Entry is not dated, timed or signed.
Enter Title
Enter Title
(N/A)
Enter Title
(N/A)
Enter Title
(N/A)
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(N/A)
Medicines
Enter Title
Each medication is entered in the SOAP as follows:
Giving med:
Drug name
Drug concentration Drug form
Amount given
Route given
Dosing Interval
Box (x’ed)
Initials
Scripting meds/writing plan to give
Drug name, drug concentration/form, amount dispensed, amount given, route given, dosing interval, dosing length.
Enter Title
One piece of information is missing
Enter Title
Multiple pieces of information are missing from the medication entry
Enter Title
Left blank
In patients with multiple medications, one or more medication is not recorded in the medical record.
Subjects:
Health
Types:
Assignment
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