iRubric: Soap Note Grading Rubric for University of the Cumberlands

Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment

Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.

Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.

Subjective assessment of health status is fully explicated<BR>
CC and HPI are targeted toward the reason for presentation without the inclusion of extraneous information.<BR>
CC is succinct.<BR>
HPI is fully developed and includes location, duration, timing, character, severity provocative/palliative factors and/or other features appropriate for the reason for presentation.<BR>
Elements of the PMH, FH, and ROS that expand on the CC and HPI are included.

Lacks differential diagnoses and/or final diagnosis is inappropriate or unacceptable for subjective and objective assessment

Limited differential diagnoses considered and/or final diagnoses only minimally applicable for subjective and objective assessment

Minimum of 5 differential diagnoses considered and appropriate final diagnoses selected for subjective and objective assessment

Greater than 5 appropriate differential diagnoses considered and evidence that final diagnoses was determined utilizing evidence-based research as applied to subjective and objective assessments

Incorrectly or fails to apply evidence-based guidelines to assesment, diagnosis, plan, patient education, or follow-up.

Includes 2 or more errors in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up

Includes only one minor error in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up

Evidence of correct application of evidence-based guidelines without omission to assessment, diagnosis, plan, patient education, or follow-up