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iRubric: Soap Note Grading Rubric

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Soap Note Grading Rubric Soap Note Grading Rubric Rubric designed to evaluate soap notes by graduate nursing students Rubric Code: ZX65476 By skidd9 Draft Public Rubric Subject: Medical Type: Assignment Grade Levels: (none)

Soap Note Grading Rubric
	Below Average 1 pts	Average 2 pts	Above Average 3 pts	Exceptional 4 pts
Documentation is clear and well org	Below Average Documentation does not meet expectations for the graduate level as evidenced by either of the following: lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.	Average Documentation meets criteria for clarity but needs to be better 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.
Subjective assessment is fully expl	Below Average Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment	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 assessment is fully expli	Below Average Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/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.
Diagnoses are adequate, coherent, a	Below Average Lacks differential diagnoses and/or final diagnosis is inappropriate or unacceptable for subjective and objective assessment	Average Limited differential diagnoses considered and/or final diagnoses only minimally applicable for subjective and objective assessment	Above Average Minimum of 5 differential diagnoses considered and appropriate final diagnoses selected for subjective and objective assessment	Exceptional Greater than 5 appropriate differential diagnoses considered and evidence that final diagnoses was determined utilizing evidence-based research as applied to subjective and objective assessments
Plan is coherent, complete, and afi	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.
Evidence-based guidelines utilized	Below Average Incorrectly or fails to apply evidence-based guidelines to assesment, diagnosis, plan, patient education, or follow-up.	Average Includes 2 or more errors in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up	Above Average Includes only one minor error in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up	Exceptional Evidence of correct application of evidence-based guidelines without omission to assessment, diagnosis, plan, patient education, or follow-up

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