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iRubric: Established Patient SOAP Note Rubric

iRubric: Established Patient SOAP Note Rubric

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Established Patient SOAP Note Rubric Established Patient SOAP Note Rubric Rubric Code: RX8CW7A By michalle Ready to use Public Rubric Subject: Medical Type: Assignment Grade Levels: Graduate

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.

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