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iRubric: SOAP Note Rubric

iRubric: SOAP Note Rubric

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SOAP Note Rubric

  Derived from rubric: SOAP Note Rubric
built by kspeer

Rubric Code: KX6C7BW
Rubric for SOAP notes created by pharmacy students on advanced rotation
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Keywords: (None)
Categories: Subjects: Medical   Pharmacy  
Types: Assignment  
Grade Levels: Graduate

Powered by iRubric Soap Note Grading Rubric
  Below Average
1 pts
Average
2 pts
Above Average
3 pts
Exceptional
4 pts
Grade
(N/A)
Background Information
CC
HPI
PMH
Med Hx
Social Hx
Allergies
ROS
Labs/Imaging
Below Average

Background information missing or completely inaccurate.
Average

Background information presented shows a cursory understanding of the patient but is not inappropriate.
Above Average

Background info shows a good understanding of the patients condition.
Exceptional

Background info is very thorough and shows full understanding of patients past and current conditions.
Grade


Subjective
Below Average

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

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

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

Subjective data is complete and accurately represents the patient's presentation.
Grade


Objective
Below Average

Objective assessment is not developed and/or the assessment is inappropriate for the presenting problem.
Average

Two or more elements needed for adequate objective evaluation of a patient's problem is missing. Includes irrelevant information.
Above Average

Objective assessment is missing an element needed for adequate evaluation of the patient's problem.
Includes irrelevant information.
Exceptional

Objective data is complete and accurately represents the patient's presentation.
Grade


Assessment
Presents hospital assessment and personal assessment.
Below Average

Lacks assessment and/or assessment is inappropriate or unacceptable based on subjective and objective data
Average

Assessment is limited and only minimally applicable to subjective and objective data. Missing information, shows basic understanding of patients condition.
Above Average

Adequate assessment of the patient. Demonstrates an underatanding of the disease states, may be missing minor information that does not affect the overall assessment.
Exceptional

Thorough assessment of the patient. Shows clear understanding of the patients disease states and current conditions. Able to critically evaluate hospital assessment and agree/disagree appropriately.
Grade


Plan
Presents hospital plan and personal plan.
Below Average

Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up.
Average

Plan is inadequate to fully address the identified problem. Able to discuss major points relating to patient care but misses much of the fine detail.
Above Average

Plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.
Exceptional

Plan is appropriate for the diagnosis and accurately addresses the problem identified. Plan is appropriate for this specific patient. Includes plans for monitoring/follow-up.
Grade


Evidence-based guidelines
Both primary and tertiary literature should be used.
Below Average

Incorrectly or fails to apply evidence-based guidelines to assesment, diagnosis, plan, patient education, or follow-up. References used are poor or missing.
Average

Includes 2 or more errors in the application or omission of evidence-based guidelines. References used are related but not ideal.
Above Average

Includes only one minor error in the application or omission of evidence-based guidelines. References used are appropriate.
Exceptional

Correct application of evidence-based guidelines without omission. References used are the best available and generate good discussion.
Grade


Documentation
Below Average

Documentation does not meet expectations for the graduate level as evidenced by either of the following:
lay terminology, illogical sequencing, missing essential elements, multiple spelling/grammatical errors.
Average

Documentation needs to be more organized.
Documentation occasionally strays from standard format for SOAP documentation.
May occasionally stray from logical sequence but the reader is able to determine findings with minimal difficulty.
Above Average

Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.
Documentation occasionally strays from standard format for SOAP documentation.
Exceptional

Documentation is clear and well organized.
Appropriate medical terminology is used.
Format follows the standard and is professionally written. Medications are presented in a manner appropriate for a pharmacist (generic name, dose, route, frequency).
Grade





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