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iRubric: SOAP Note Rubric

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SOAP Note Rubric SOAP Note Rubric Rubric to grade a MA SOAP note Rubric Code: RX743X6 By riedlr Ready to use Public Rubric Subject: Medical Type: Project Grade Levels: Undergraduate

SOAP Note Rubric
	Fail (0-6) (N/A)	Good (7 -9) (N/A)	Excellent (10-20) (N/A)
Subjective History of Patient Illness	Fail (0-6) Gives no information	Good (7 -9) Gives small amount of pertinent information or incomplete ideas of the patient.	Excellent (10-20) Provides Chief complaint, any current medications, symptoms, and activities of daily living. This information reflects the true feelings of the patient.
Objective The section needs to include: 1. Length of time, where, and for what the client was seen. 2. Report WHAT YOU SEE (chronologically or by categories)	Fail (0-6) Not objective No skill OT reflected Client is judged You write what YOU did. Poor grammar and spelling. Messy, not professional looking	Good (7 -9) Do not include measurable skills worked on Fair grammar and spelling, therefore although errors are present, note is understandable	Excellent (10-20) All elements present. Excellent grammar, spelling. Very professional
Assessment Go into each data of the objective section, asking yourself what problems, progress, do you see. So what?... Why is this important to the client. Anything that is less than WNL's should be addressed regarding impact on client's performance areas. Include education areas. End with: CLIENT WILL BENEFIT FROM	Fail (0-6) Elements present in the objective section not discussed or new elements discussed which were not mentioned in the Objective. Goals do not meet ABCDE criteria Poor grammar and spelling. Messy, not professional looking	Good (7 -9) 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	Excellent (10-20) All elements present. Excellent grammar, spelling. Very professional
Plan How often will the client be seen and for how long. What are you going to be working on, or if client will be discharged.	Fail (0-6) Missing two or more elements element Goals do not meet ABCDE criteria	Good (7 -9) Missing one element. Fair grammar and spelling, therefore although errors are present, note is understandable	Excellent (10-20) All elements present. Excellent grammar, spelling. Very professional
Use of Correct Terminology Correct Terminology and Abbreviations will be utilized in documentation	Fail (0-6) Missing Terminology No abbreviations used Incorrect format.	Good (7 -9) Some terminology was used. Some Abbreviations was used. Poorly organized.	Excellent (10-20) Uses proper headings and sub-headings. Overall product is easy to read and well organized. Correct Terminology is utilized.