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iRubric: SOAP Rubric

iRubric: SOAP Rubric

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SOAP Rubric 
Rubric Code: W3C5A3
By kkomurek
Ready to use
Public Rubric
Subject: Health  
Type: Assignment  
Grade Levels: Undergraduate

Powered by iRubric 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.
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  Enter Title

(N/A)

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(N/A)

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(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.




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