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iRubric: SOAP Documentation and Patient Chart rubric

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SOAP Documentation and Patient Chart SOAP Documentation and Patient Chart Appropriate data entry for patient charting Rubric Code: F2X6274 By jjballardhouse Draft Public Rubric Subject: Medical Type: Assessment Grade Levels: Graduate

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 findings, and or techniques/modalities and or response to treatment is absent or not relational to the subjective information.	Meets Standard Student is clear on findings during the massage session that correlate to the subjective information, but is techniques/modalities done to treat the objective findings are either not clear or do not appropriately fit, or the student is unclear on the location/duration of the massage, or the response to the treatment is vague.	Exceeds Standard Detailed information pertaining to findings, match with the techniques/modalities, duration given and the response to treatment matches with the subjective information.
Assessment	Needs Improvement Student leaves out STG's and/or LTG's or goals are present and do not correlate with the subjective and objective information and/or functional outcomes are absent.	Meets Standard Student gives appropriate STG's and LTG's based on the subjective and objective findings but functional outcomes are unclear and do not correlate with the health history	Exceeds Standard Student gives appropriate STG's and LTG's that match the subjective and objective information and gives correct functional outcomes based on their findings along with the health history.
Plan	Needs Improvement Student leaves out or is unclear of future treatment and or frequency of massages and homework and self-care activities are absent from documentation.	Meets Standard Student gives appropriate future treatments and frequency of massages yet homework and self-care activities are vague or do not match appropriately with their S,O,A documentation.	Exceeds Standard Student gives appropriate future treatment and frequency of massages along with beneficial homework and self-care activities that match with the S,O,A sections of their documentation.
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.	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, black pen is used and corrections are crossed out with student initials beside mistake.
Patient Chart
	Not Exceptable 0 pts	* 0 pts	Excellent 10 pts
Signature	Not Exceptable Student does not sign the bottom of patient SOAP notes and Today's Session Plan.	*	Excellent Student signs the bottom of patient SOAP notes and the Today's session plan.
Organization	Not Exceptable Patient folders are turned in out of order.	*	Excellent Student turns in Patient chart in proper documented order.
Consent	Not Exceptable Student does not properly document consent form with signature and/or initials.	*	Excellent Student documents review of policies and procedures by proper documentation and signature.
Patient Log List	Not Exceptable Student does not log their patient list sessions and dates in their turned in their folder, or does not turn in their folder but does complete patient soap notes on time.	*	Excellent Student submits their folder on time with client list documented inside with date of session.
Student Log List in Patient folder	Not Exceptable Student does not log their name on the student therapist list in patients folder with date.	*	Excellent Student documents themselves as the practicing massage therapy student in the log list behind the patients health history form with their name and date.

	LATE 0 pts	Enter Title (N/A)	On Time 50 pts
SOAP notes turned in on time	LATE Student does not turn in SOAP notes on time.	Enter Title	On Time Student turns in SOAP notes on time.

Keywords:

Documentation, SOAP note

Subjects:

Medical

Types:

Assessment

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