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iRubric: SOAP Note Rubric

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SOAP Note Rubric SOAP Note Rubric Rubric to grade a SOAP note Rubric Code: GX4ABBC By ecruz004 Ready to use Public Rubric Subject: Health Type: Writing Grade Levels: (none)

SOAP Note Rubric grading a SOAP note
	Fail 1 (N/A)	Pass 2 (N/A)	Good 3 (N/A)	Excellent 4 (N/A)
Subjective 25 % Statements made by the patient, family and/or staff that may impact treatment.	Fail 1 The statement was not subjective or did not reflect the patient/client	Pass 2 N/A	Good 3 N/A	Excellent 4 Statement is a true reflection of the patient
Objective 25 % What did you do in treatment? Why? Picture of the treatment that another therapist could reproduce. Includes measurable, quantifiable, observable data obtained through your treatment. The "why" makes it a skilled service.	Fail 1 Not objective No skill OT reflected Client is judged You write what YOU did. Poor grammar and spelling. Messy, not professional looking	Pass 2 Do not include measurable skills worked on Fair grammar and spelling, therefore although errors are present, note is understandable	Good 3 Missed what you are seeing the client for, or setting, or for how long Minimal grammar or spelling errors (< 3).	Excellent 4 All elements present. Excellent grammar, spelling. Very professional
Assessment 25 % How did it go? Assess the tasks you completed in O. If you did not write it in O you can not assess it. Consists of appraisal of pro-gress, limitations, pertinent issues, and expected gains. Justification for treatment.	Fail 1 Elements present in the objective section not discussed or new elements discussed which were not mentioned in the Objective. Goals do not meet criteria Poor grammar and spelling. Messy, not professional looking	Pass 2 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	Good 3 Missed relating treatment and use of OT to patient's goals and POC. Minimal grammar or spelling errors (< 3).	Excellent 4 All elements present. Excellent grammar, spelling. Very professional
Plan 25 % What needs to happen in the next session? Next step based on assessment.	Fail 1 Missing two or more elements element Goals do not meet criteria	Pass 2 Missing one element. Fair grammar and spelling, therefore although errors are present, note is understandable	Good 3 No elements missing Minimal grammar or spelling errors (< 3).	Excellent 4 All elements present. Excellent grammar, spelling. Very professional