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iRubric: SOAP notes rubric

iRubric: SOAP notes rubric

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SOAP notes 
Friends and Family SOAP notes
Appropriate data entry for patient charting
Rubric Code: SX2X29A
By joysspa
Draft
Public Rubric
Subject: Medical  
Type: Assessment  
Grade Levels: Graduate

Powered by iRubric SOAP component description
  Needs Improvement

2.5 pts

Meets Standard

5 pts

Exceeds Standard

10 pts

Subjective

Needs Improvement

- missing significant information about reason for visit. And/or student does not correlate patient's health history information and or interview onto soap notes.
Meets Standard

- minimal data about presenting compalint or reason for visit. Student leaves out a minimum of 2 pertinent items from patient's health history forms, or shared information during the session.
Exceeds Standard

- detailed information describing presenting complaint or reason for visit. Student correlates information found from health history forms, interview and massage session completely.
Objective

Needs Improvement

- absent or significant data omitted from documentation. Student neglects specificity to objectives.
Meets Standard

- minimal information present or pertinent to presenting condition or reason for visit. Student's observation is vague to details presented during massage session.
Exceeds Standard

- detailed information pertaining to presenting condition or reason for visit.
Assessment

Needs Improvement

- absent treatment given and/or changes due to massage of patient's condition. Pain levels not reassed after massage. Student neglected to chart patient improvements from the session.
Meets Standard

- appropriate assessment of patient's condition and massage treatment given. Student is gives minimal information on massage treatment or does not clearly re-evaluate changes due to the massage
Exceeds Standard

- Student gives detailed information to the massage treatment given and changes due to the massage. Student clearly gives a detailed assessment of patient's condition, and provides information to the massage applications given/avoided to correlate with the objectives.
Plan

Needs Improvement

- absent or inappropriate homework or plans and or goals for the patient.
Meets Standard

- Student includes appropriate homework and plans for the patients next session, but does not include long range plans or goals for the patients.
Exceeds Standard

- detailed documentation of homework, plan for the patient's next session. Student attempts to forsee long range plans and goals for the patient.
Short hand documentation
  Needs Improvement

2.5 pts

Fair

5 pts

Excellent

10 pts

Abbreviations

Needs Improvement

Student does not use abbreviations on three or more words where needed. Student does not clearly document SOAP notes
Fair

Student does not use abbreviations on two or less words.
Excellent

Student clearly writes SOAP notes in abbreviation form where needed.
Legible SOAP documention
  Needs Improvement

2.5 pts

Fair

5 pts

Excellent

10 pts

Clearly written

Needs Improvement

Instructor has difficulty reading SOAP notes. or corrections are whited out/scratched out with a pen or correct use of colored pen is not used.
Fair

Student does not use correct spelling in SOAP notes.
Excellent

Student clearly writes out SOAP notes in a clear fashion that is easy to read. Spelling is correct, blue pen is used and corrections are crossed out with student initials beside mistake.
Student Signed SOAP notes
  Not Exceptable

0 pts

*

0 pts

Excellent

10 pts

Signature

Not Exceptable

Student does not sign the bottom of patient SOAP notes.
*
Excellent

Student signs the bottom of patient SOAP notes.



Keywords:
  • Documentation, SOAP note

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