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iRubric: SOAP Note Rubric

iRubric: SOAP Note Rubric

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SOAP Note Rubric

  Derived from rubric: SOAP Note Rubric
built by hitomiy1891

Rubric Code: JX7B3W8
Rubric for SOAP notes created by pharmacy students on advanced rotation
ready Ready to use    public Public Rubric

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Keywords: (None)
Categories: Subjects: Medical   Pharmacy  
Types: Assignment  
Grade Levels: Graduate

Powered by iRubric 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.



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