RCampus - Learning, ePortfolios, Assessments, Outcomes
Enter your login name here, or click here to go to the login page.
Enter your password:
forgot?   | click here to create a free account.
iRubric: Established Patient SOAP Note Rubric

iRubric: Established Patient SOAP Note Rubric

preview rubric

 

edit print email Copy to my rubrics Bookmark test run apply to... delete

Established Patient SOAP Note Rubric built by michalle

Rubric Code: RX8CW7A
ready Ready to use    public Public Rubric

Directly link to this rubric or embed it on your website:
url:
link:
embed:
Keywords: (None)
Categories: Subjects: Medical  
Types: Assignment  
Grade Levels: Graduate

Powered by iRubric Established Patient SOAP Note
Enter rubric description
  Exceptional
20 pts
Satisfactory
15 pts
Marginally Acceptable
10 pts
Unacceptable
0 pts
Subjective
Exceptional

A fully explicated CC and HPI that targets the reason for presentation without the inclusion of extraneous information. HPI is fully developed and includes components of OLDCART. Elements of the PMH, FH, and ROS that expand on the CC and HPI are included
Satisfactory

Subjective assessment is missing no more than 2 elements that are needed for an adequate evaluation of the patient's problem; however, records pertinent positives and pertinent negatives appropriately.
Marginally Acceptable

Subjective assessment is missing 3-5 elements that are needed for an adequate evaluation of the patient's problem, and/or records pertinent postives and pertinent negatives with some inclusion of irrelevant information.
Unacceptable

Subjective assessment is missing greater than 5 elements that are needed for an adequate evaluation of the patient's problem, and/or irrelevant information predominates the subjective assessment.
Objective
Enter description
Exceptional

Objective assessment of health status is fully explicated. Physical exam includes vital signs, height and weight where appropriate, and any relevant documentation of the organ system(s) evaluated. Includes relevant diagnostic studies/laboratory results.
Satisfactory

Objective assessment is missing no more than 2 elements that are needed for an adequate evaluation of the patient's problem. Records pertinent positives and pertinent negatives appropriately.
Marginally Acceptable

Objective assessment is missing 3-5 elements that are needed for an adequate evaluation of the patient's problem. Records pertinent postives and pertinent negatives with some inclusion of irrelevant information.
Unacceptable

Objective assessment is missing greater than 5 elements that are needed for an adequate evaluation of the patient's problem. Objective assessment is not appropriate for the evaluation of the presenting problem.
Assessment
Enter description
Exceptional

Thorough assessment of the patient including a well thought out differential diagnoses. Shows clear understanding of the patient's disease state(s) and current condition(s).
Satisfactory

Adequate assessment of the patient, demonstrating a good understanding of the patient's disease state(s) and current condition(s). Missing some minor information that does not affect the overall assessment.
Marginally Acceptable

Assessment is limited and is minimally applicable to the subjective and objective data. Missing information that shows a basic understanding of the patient's disease state(s) and current condition(s).
Unacceptable

Assessment is inappropriate or unacceptable based on the subjective and/or objective data obtained.
Plan
Exceptional

Plan is appropriate for the diagnosis and accurately addresses the probelm identified. Plan is individualized and includes plans for further evaluations, diagnostic studies or labortory work to be ordered, and follow up care as appropriate.
Satisfactory

Plan is appropriate according to the exceptional criteria, but is "generic" instead of being individualized to the patient.
Marginally Acceptable

Plan is inadequate to fully address the identified problem, or the plan is too expansive indicating a basic deficiency in understanding what's appropriate based upon the patient's presenting problem.
Unacceptable

Plan is inappropriate , lacking essential components related to the assessment, and neglects patient follow up.
Documentation
Exceptional

Documentation is clear and well organized in a logical manner. Redundant or distracting information is omitted. Appropriate medical terminology is used. Stays within the SOAP note format.
Satisfactory

Documentation for the most part is clear and organized, but could use some improvement Occasional redundant or distracting information is included. Occasional misuse of medical terminology is used.
Marginally Acceptable

Documentation needs to be more organized in a logical sequence for optimal clarity. However, the assessment and plan can still be determined without difficulty. Different elements of the note stray from the SOAP note format. Needs improvement on the appropriate use of medical terminology.
Unacceptable

Documentation does not meet expectations as evidenced by any of the following: disorganized, illogical sequencing for clarity, missing essential elements, and/or multiple grammatical errors.



Discuss this rubric



Do more with this rubric:

Preview

Preview this rubric.

Edit

Modify this rubric.

Copy

Make a copy of this rubric and begin editing the copy.


Print

Show a printable version of this rubric.

Categorize

Add this rubric to multiple categories.

Bookmark

Bookmark this rubric for future reference.
Assess

Test run

Test this rubric or perform an ad-hoc assessment.

Grade

Build a gradebook to assess students.

Collaborate

Apply this rubric to any object and invite others to assess.
Share

Publish

Link, embed, and showcase your rubrics on your website.

Email

Email this rubric to a friend.

Discuss

Discuss this rubric with other members.
 

Do more with rubrics than ever imagined possible.

Only with iRubrictm.


Bookmark this page:   RCampus RCampus   twit this twitter   delicious del.icio.us   digg Digg   facebook Facebook  
About Education Sites & Communities My Account Support
About RCampus
Terms of Use
Security & Privacy
Site Map
Case Studies
Classrooms
ePortfolios
Rubrics
Coursework
Grades
Book Exchange
Tutors
Website Gallery
Basic Groups
Study Groups
Club websites
Faculty Groups
My Account Settings
My Messages
My Calendar
My To-do List
My Favorites
My Documents
Free Sign up
Log in
Help & FAQ
Contact Us
Copyright © 2017 Reazon Systems, Inc.  All rights reserved.