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iRubric: SOAP Note- OSCE rubric
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SOAP Note- OSCE
Written H&P - Summative Evaluation
Rubric Code:
A2X5CB8
By
mzarko
Ready to use
Public Rubric
Subject:
Medical
Type:
Assessment
Grade Levels:
Graduate
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Mobile Mode
SOAP Note
Complete/Proficient
3 pts
Parital/Adequate
1 pts
Absent/Inadequate
0 pts
Identifying Data
Complete/Proficient
Includes patients, name, date of birth, source of information, reliability of source and referral source (if patient was referred).
Parital/Adequate
Incomplete information.
Absent/Inadequate
Not documented.
Chief Complaint
Complete/Proficient
Documents the patient's primary reason for presenting to the office in the patient's own words and includes symptoms duration.
Parital/Adequate
Documents the primary reason but it is not in the patients words and/or does not include duration of symptoms.
Absent/Inadequate
Not documented.
History of Present Illness
Complete/Proficient
Documents a clear, organized, chronological description of the presenting problem including a detailed description of the symptoms (OLDCARTS).
Documents the presence and/or absence relevant of medical illness/conditions, family history and social history.
Documents relevant positive and negative review of systems.
Parital/Adequate
Documents a description of the presenting problem (OLDCARTS) but it is not clear or organized.
Documentation of relevant medical history, family history, social history and review of systems is present but not complete.
Absent/Inadequate
Document is unorganized and does not provide a clear picture of the presenting symptom. Relevant history and/or review of systems is minimal and/or missing key data.
Past Medical History
Complete/Proficient
Documents a focused past medical history including the presence/absence of conditions relevant to the presenting problem.
Medication list does includes all required information (dose, frequency, route)
Allergies include reaction type.
Parital/Adequate
Documents a focused past medical history but information is incomplete from the medical history, medication list and/or allergies. It is missing some information that helps narrow the differential diagnosis but it is overall still helpful.
Absent/Inadequate
Incomplete or missing components of the history.
Medications and/or allergies are incomplete.
Family History
Complete/Proficient
Documents a focused medical history including he presence/absence of conditions relevant to the presenting problem.
Parital/Adequate
Documents a focused medical history including but it is missing information about the presence/absence of some conditions relevant to the presenting problem.
Absent/Inadequate
Documentation is limited and/or missing relevant information.
Social History
Complete/Proficient
Documents a focused social history relevant to the presenting problem.
Parital/Adequate
Documents a focused social history relevant to the presenting problem but it is missing some relevant information.
Absent/Inadequate
Not documented or is missing information that is needed to narrow the differential diagnosis.
Review of Systems
Complete/Proficient
Documents a focused and thorough review of systems. Includes the system most likely to be related to the presenting problem and at least 3 other systems.
Includes at least 3 relevant positive and/or negative symptoms for each system reviewed.
The documented ROS includes information that helps narrow the differential diagnosis.
Parital/Adequate
Documents a focused review of systems for all relevant systems but it is missing some information that helps narrow the differential diagnosis but it is overall still helpful.
Absent/Inadequate
Does not document a review of systems or documentation is missing relevant systems.
The documented ROS does not includes enough relevant information that help narrow the differential diagnosis.
Physical Examination
Complete/Proficient
Documents a focused examination, including the presence and/or absence of pertinent exam findings needed to evaluate the presenting problem. The documented examination helps narrow the differential diagnosis.
Parital/Adequate
Documents a focused examination, but it is missing details about the presence and/or absence of pertinent exam findings needed to evaluate the presenting problem. The documented examination is still sufficient to narrow the differential diagnosis.
Absent/Inadequate
Documentation is missing systems and/or it is missing details about the presence and/or absence of pertinent exam findings that are crucial to evaluating the presenting problem. The documented examination does not help narrow the differential diagnosis.
Diagnostic Studies: Labs, Imaging, etc.
Complete/Proficient
Documents diagnostic studies relevant to the presenting problem.
Includes results.
Studies and results clearly narrow the differential diagnosis.
Parital/Adequate
Documents diagnostic studies but they are not all relevant to the presenting problem and/or studies are missing.
Results are incomplete but the information is sufficient to narrow the differential diagnosis.
Absent/Inadequate
Missing several studies and/or data is missing which is needed to narrow the differential diagnosis.
Assessment
Complete/Proficient
Summarizes the patient and chief complaint. Documents a Problem List including a diagnosis or list of differential diagnoses for each problem. Supports the diagnosis/differential diagnosis with subjective and/or objective data.
Overall, The assessment demonstrates that the learner can organize the subjective and objective information given and formulate a diagnosis or differential diagnosis. The learner's impression of the patient's symptoms is clear to the reader.
Parital/Adequate
All components are present. Overall, the assessment demonstrates that the learner has obtained the information to arrive at a diagnosis or differential diagnosis but the rational is not clear. The learner's impression of the patient's symptoms in not clear to the reader.
Absent/Inadequate
Missing components
-or-
The assessment does not demonstrates that the learner has obtained the necessary information to arrive at a diagnosis or differential diagnosis. It is not organized and the learner's impression of the patient's symptoms in not clear to the reader.
Plan
Complete/Proficient
Documents a well organized plan for each problem on the problem list.
The plan demonstrates clinical reasoning and includes appropriate diagnostic studies, treatments plan, patient education and, follow up.
Parital/Adequate
Documents a well organized plan for each problem on the problem list.
The plan includes includes a combination of: diagnostic studies, treatments plan, patient education and, follow up.
Components of the plan are incomplete or irrelevant.
Absent/Inadequate
The plan is incomplete or poorly organized. The workup, treatment and/or follow up is unclear.
Subjects:
Medical
Types:
Assessment
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