iRubric: SOAP Note Rubric

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SOAP Note Rubric

Rubric to grade a SOAP note

Rubric Code: NX32C35

By drtmaxwell

Ready to use

Public Rubric

Subject: Health

Type: Writing

Grade Levels: Graduate

SOAP Note Rubric grading a SOAP note
	Poor 60 pts	Fair 70 pts	Good 80 pts	Excellent 100 pts
Subjective 25 % Statements made by the patient, family and/or staff that may impact treatment.	Poor The statement was not subjective or did not reflect the patient/client	Fair The statement was not subjective incomplete or did not fully reflect the patient/client	Good The statement was subjective (semi-complete) did reflected the patient/client.	Excellent Statement is a true reflection of the patient
Objective 25 % What did you/provider do in treatment? Why? Picture of the treatment that another therapist could reproduce. Includes measurable, quantifiable, observable data obtained through your treatment. The "why" makes it a skilled service.	Poor Not objective No skill, poor thought process. You write what YOU/Provider did. Poor grammar and spelling. Messy, not professional looking	Fair Do not include measurable skills worked on Fair grammar and spelling, therefore although errors are present, note is understandable	Good Missed what you are seeing the client for, or setting, or for how long Minimal grammar or spelling errors (< 3).	Excellent All elements present. Excellent grammar, spelling. Very professional
Assessment 25 % How did it go? Assess the tasks you completed in O. If you did not write it in O you can not assess it. Consists of appraisal of progress, limitations, pertinent issues, and expected gains. Justification for treatment.	Poor Elements present in the objective section not discussed or new elements discussed which were not mentioned in the Objective. Goals do not meet criteria Poor grammar and spelling. Messy, not professional looking	Fair 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 Missed relating treatment and use of OT to patient's goals and POC. Minimal grammar or spelling errors (< 3).	Excellent All elements present. Excellent grammar, spelling. Very professional
Plan 25 % What needs to happen in the next session? Next step based on assessment.	Poor Missing two or more elements element Goals do not meet criteria, plan does not match Differentials(2) Urgent care (3) for Family Practice note are not cohesive with diagnosis	Fair Missing one element. Fair grammar and spelling, therefore although errors are present, note is understandable. Goals are and plan are vague, Differentials(2) Urgent care (3) for Family Practice are within note but are incomplete/not fully cohesive with diagnosis	Good No elements missing Minimal grammar or spelling errors (< 3). Goals are semi accurate Differentials(2) Urgent care (3) for Family Practice are semi complete and are semi cohesive with diagnosis	Excellent All elements present. Excellent grammar, spelling. Very professional Goals are accurate Differentials(2) Urgent care (3) for Family Practice are complete and are fully cohesive with diagnosis

Keywords:

SOAP note, medical documentation

Subjects:

Health

Types:

Writing

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