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iRubric: SOAP Note Rubric

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SOAP Note Rubric Progress notes provide evidence that a session took place and the effects of treatment. From the progress note, a reader should be able to ascertain the client's diagnosis, current issues, and effects of counseling. Rubric Code: G234633 By makautzman Ready to use Public Rubric Subject: Psychology Type: Assessment Grade Levels: Graduate

SOAP Note Rubric
	Poor Needs Improvement 1 pts	Fair Competent 2 pts	Good Outstanding documentation 3 pts
S (Subjective) Information includes statements presented to the counselor such as the presenting problem, statements from others, and historical data.	Poor Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.	Fair Well organized; partial but accurate summary of pertinent information (>80%).	Good A complete and concise summary of pertinent information.
O (Objective) Specific information that can be compared to previous data or used as a baseline for future objective observations.	Poor Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.	Fair Partial but accurate summary of pertinent information (>80%).	Good A complete and concise summary of pertinent information.
A (Assessment) A written evaluation of the current session and how it relates to the cumulate scope of counseling. Should include some combination of the 9 types of information identified in Wiger text.	Poor Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included. Assessment is present for 50-80% of problems. Appropriate therapeutic goals for a few identified problems (50%-80%).	Fair Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%). An assessment is present for each problem listed but not optimal. Appropriate therapeutic goals for most identified problems (>80%).	Good A Complete problem list is generated and rationally prioritized; no extraneous information or issues are listed. An optimal and thorough assessment is present for each problem. Appropriate and relevant therapeutic goals for each identified problem.
P (Plan) Focuses on the future of treatment based on the client's current functioning level.	Poor Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).	Fair Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.	Good Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.