Skip to main content
iRubric: SOAP Note rubric

iRubric: SOAP Note rubric

find rubric

edit   print   share   Copy to my rubrics   Bookmark   test run   assess...   delete   Do more...
SOAP Note 
SOAP Note
The purpose of this performance assessment is to determine if physicians have gained the skills necessary to accurately create a SOAP note in the Electronic Medical Record. The SOAP note has four components (subjective, objective, assessment, and plan) which is how physicians document their patient visits. SOAP notes in the electronic medical record must be accurate and also be created following Medicaid guidelines. The rubric below will be one method used for grading the SOAP note process.
Rubric Code: VX34688
By Tanya_Magee
Ready to use
Public Rubric
Subject: Health  
Type: Assessment  
Grade Levels: (none)

Powered by iRubric SOAP Note Creation
  Distinguished

5 pts

Proficient

4 pts

Basic

3 pts

Below Expectations

2 pts

Non-Performance

1 pts

Review Model SOAP Note

Review an accurate SOAP containing all 5 elements. (subjective, objective, assessment, plan, and Medicaid criteria) in the training environment.
Distinguished

The learner reviewed all 5 of the review items.
Proficient

The learner reviewed 3 or 4 of the review items.
Basic

The learner reviewed 1 or 2 of the review items.
Below Expectations

The learner reviewed 1 of the review items.
Non-Performance

The learner reviewed none of the review items.
Simulation Worksheet

The learner having viewed the patient visit simulation in the EMR training system will gather and analyze data to determine which simulation data should be input into the training EMR
Distinguished

All 7 of the data elements were gathered and analyzed to make a determination for which data should be input into the training EMR.
Proficient

5 or 6 data elements from the 7 patient examination criteria were gathered and analyzed to make a determination for which data should be input into the training EMR.
Basic

3 or 4 data elements from the 7 patient examination criteria were gathered and analyzed to make a determination for which data should be input into the training EMR.
Below Expectations

1 or 2 data elements from the 7 patient examination criteria were gathered and analyzed to make a determination for which data should be input into the training EMR.
Non-Performance

None of the data elements from the 7 patient examination criteria were gathered and analyzed to make a determination for which data should be input into the training EMR.
Data Analysis Rationale

Learners will use the bottom of the worksheet to rationalize usefulness of the 7 patient examination criteria. Those criteria are the patient's current symptoms, past and present medical history, family history, allergies, medications, and medical problems.
Distinguished

The learner's data analysis rationale was completely clear, structured, and well thought out.

Errors in analysis were none existent and 5 to 7 are useful in creating an accurate SOAP note.
Proficient

The learner's data analysis rationale was mostly clear, structured, and well thought out.

Errors in analysis were minor and 3 to 4 are useful in creating an accurate SOAP note.
Basic

The learner's data analysis rationale was somewhat clear.

Errors in analysis were major and only 1 or 2 are useful in creating an accurate SOAP note.
Below Expectations

The learner's data analysis rationale was unclear.

Errors in analysis were grievous and are none are useful in creating an accurate SOAP note.
Non-Performance

The learner's did not provide a data analysis rationale.

No data is available that would be useful in creating an accurate SOAP note.
Compile the SOAP Note

Arrange the 4 SOAP note components (subjective, objective, assessment, and plan) and apply for Medicaid billing concepts that govern SOAP notes.
Distinguished

The SOAP note arrangement and Medicaid billing concept application followed all of the compilation rules taught in class.
Proficient

The SOAP note arrangement and Medicaid billing concept application followed most of the compilation rules taught in class.
Basic

The SOAP note arrangement and Medicaid billing concept application followed some of the compilation rules taught in class.
Below Expectations

The SOAP note arrangement and Medicaid billing concept application followed few if any of the compilation rules taught in class.
Non-Performance

The SOAP note arrangement and Medicaid billing concept application followed none of the compilation rules taught in class.
Create the SOAP Note

Create a SOAP note in the progress note section of the patient chart in the training environment.
Distinguished

The SOAP note had 8 to 11 of the following: 4 SOAP note components, 7 patient examination criteria, criteria, and Medicaid billing concepts.
Proficient

The SOAP note had 5 to 7 of the following: 4 SOAP note components, 7 patient examination criteria, criteria, and Medicaid billing concepts.
Basic

The SOAP note had 2 to 4 of the following: 4 SOAP note components, 7 patient examination criteria, criteria, and Medicaid billing concepts.
Below Expectations

The SOAP note had 1 of the following: 4 SOAP note components, 7 patient examination criteria, criteria, and Medicaid billing concepts.
Non-Performance

The SOAP note was not created.



Keywords:
  • SOAP EDU:358 tbarr



Discuss this rubric




Do more with this rubric:
Preview

Preview

Preview this rubric.
Edit

Edit

Modify this rubric.
Copy

Copy

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

Print

Print

Show a printable version of this rubric.
Categorize

Categorize

Add this rubric to multiple categories.
Bookmark

Bookmark

Bookmark this rubric for future reference.
Assess
Test run

Test run

Test this rubric or perform an ad-hoc assessment.
Grade

Grade

Build a gradebook to assess students.
Collaborate

Collaborate

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

Publish

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

Email

Email this rubric to a friend.
Discuss

Discuss

Discuss this rubric with other members.
 

Do more with rubrics than ever imagined possible.

Only with iRubrictm.


Copyright © 2024 Reazon Systems, Inc.  All rights reserved.
n98