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iRubric: SOAP Note Rubric

iRubric: SOAP Note Rubric

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SOAP Note Rubric 
Rubric to grade a SOAP note
Rubric Code: N244B49
Ready to use
Public Rubric
Subject: Health  
Type: Writing  
Grade Levels: (none)

Powered by iRubric SOAP Note Rubric
Enter rubric description
  Fail (0-6)

(N/A)

Pass (7 -7.9)

(N/A)

Good (8-8.9)

(N/A)

Excellent (9-10)

(N/A)

Subjective
5 %

Use something significant the client says about his/her treatment or condition

Fail (0-6)

The statement was not subjective or did not reflect the patient/client
Pass (7 -7.9)

N/A
Good (8-8.9)

N/A
Excellent (9-10)

Statement is a true reflection of the patient
Objective
40 %

The section needs to include:
1. Length of time, where, and for what the client was seen.
2. Report WHAT YOU SEE (chronologically or by categories)
3. Deemphasize the media. Leave yourself out, Focus on the client's response, do not be judgmental, specify when and how much assistance was needed, show skilled OT happening
Response to patient or caregiver's education.

Fail (0-6)

Not objective
No skill OT reflected
Client is judged
You write what YOU did.
Poor grammar and spelling.
Messy, not professional looking
Pass (7 -7.9)

Do not include measurable skills worked on
Fair grammar and spelling, therefore although errors are present, note is understandable
Good (8-8.9)

Missed what you are seeing the client for, or setting, or for how long
Minimal grammar or spelling errors (< 3).
Excellent (9-10)

All elements present. Excellent grammar, spelling. Very professional
Assessment
40 %

Go into each data of the objective section, asking yourself what problems, progress, and rehab problems do you see.
So what?... Why is this important to the client. Anything that is less than WFL's should be addressed regarding impact on client's performance areas.
Include education areas.
End with: CLIENT WILL BENEFIT FROM SKILLED OT SERVICES IN ORDER TO .....
Goals may be included (according to some authors)

Fail (0-6)

Elements present in the objective section not discussed or new elements discussed which were not mentioned in the Objective.
Goals do not meet ABCDE criteria
Poor grammar and spelling.
Messy, not professional looking
Pass (7 -7.9)

No justification for continued OT or no mention of why client is been discharged.
Fair grammar and spelling, therefore although errors are present, note is understandable
Good (8-8.9)

Missed relating treatment and use of OT to patient's goals and POC.
Minimal grammar or spelling errors (< 3).
Excellent (9-10)

All elements present. Excellent grammar, spelling. Very professional
Plan
15 %

How often will the client be seen and for how long.
What are you going to be working on, or if client will be discharged.
Goals may be included (according to some authors)

Fail (0-6)

Missing two or more elements element
Goals do not meet ABCDE criteria
Pass (7 -7.9)

Missing one element.
Fair grammar and spelling, therefore although errors are present, note is understandable
Good (8-8.9)

No elements missing
Minimal grammar or spelling errors (< 3).
Excellent (9-10)

All elements present. Excellent grammar, spelling. Very professional



Keywords:
  • SOAP note, medical documentation

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