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iRubric: Soap Note Grading Rubric - GOOD FOR SOAP with Reflection
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Soap Note Grading Rubric - GOOD FOR SOAP with Reflection
Soap Note Grading Rubric - GOOD FOR SOAP with Reflection
Rubric designed to evaluate soap notes by graduate nursing students
Rubric Code:
P2X6973
By
susanbown
Ready to use
Public Rubric
Subject:
Nursing
Type:
Assignment
Grade Levels:
Graduate
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Soap Note Grading Rubric
Exceptional
5 pts
Above Average
4 pts
Average
3 pts
Below Average
2 pts
Score
(N/A)
Subjective
Exceptional
Subjective assessment of health status is fully explicated<BR>
CC and HPI are targeted toward the reason for presentation without the inclusion of extraneous information.<BR>
CC is succinct.<BR>
HPI is fully developed (e.g., includes thorough symptom analysis and/or other features appropriate for the reason for presentation.<BR>
Elements of the PMH, FH, and ROS that expand on the CC and HPI are included
Above Average
Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.
Average
Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.
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
Score
Objective
Exceptional
Objective assessment of health status is fully explicated<BR>
Physical exam includes vital signs, height and weight for all children and for others as appropriate, any relevant developmental data related to assessment of CC, and objective findings relevant to CC and supporting of Assessment and Plan.<BR>
Appropriate diagnostic tests are performed/ordered.
Above Average
Objective assessment is missing an element needed for adequate evaluation of the patient's problem.<BR>
Includes irrelevant information<BR>
Selection of diagnostic tests is too broad or expensive for evaluating the presenting problem OR<BR>
Selection of diagnostic tests is inadequate to address the presenting problem
Average
Two or more elements needed for adequate evaluation of a patient's problem is missing from the subjective and/or objective assessment.<BR>
Selection of diagnostic tests is inappropriate for CC or is missing when needed.
Below Average
Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/or inappropriate for the presenting problem.
Score
Diagnoses
Exceptional
Complete problem list is generated and rationally prioritized. <BR> No extraneous information or issues are listed.<BR> An optimal and thorough assessment is present for each problem. <BR> Diagnoses reflect application of best clinical evidence to subjective and objective assessments. <BR>
Above Average
Problem list is missing one element, or is inappropriately prioritized, but diagnoses are well supported by subjective and objective assessment.
Average
Problem list is missing one element, or is inappropriately prioritized, and diagnoses are not sufficiently supported by subjective and objective assessment.
Below Average
Diagnoses are inappropriate or unsupported by subjective and objective assessment
Score
Plan
Exceptional
Plan is coherent and complete and accurately addresses identified problem(s).<BR> Plan reflects best clinical evidence. <BR> Plan is patient-centered and reflects interprofessional collaboration. <BR>
Plan includes plans for evaluation/follow-up care as appropriate. <BR> Plan is individualized to the patient's age, development, culture, religion, family, environment, education, and psychosocial concerns. <BR> Plan is economically sound. <BR>
Above Average
Plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.
Average
Plan is inadequate to fully address the identified problem.expansive or overwhelming for the client or healthcare system OR<BR>
Needs to consider alternative features for optimal outcomes
Below Average
Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up.
Score
Evidence
Exceptional
Identification of evidence-based guidelines to assessment, diagnosis, plan, patient education, and/or follow-up, with appropriate application of evidence, indicating rationale(s) for implementation and considering patient preferences.
Above Average
Includes only one minor error in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up
Average
Includes 2 or more omissions or errors in application of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up
Below Average
Incorrectly or fails to apply evidence-based guidelines to assesment, diagnosis, plan, patient education, or follow-up.
Score
Documentation
Exceptional
Documentation is well organized and correctly formatted.<BR>
Language is clear with appropriate medical terminology. <BR>
No redundant, extraneous, or distracting information. <BR>
Narratives have a logical flow.
Above Average
Documentation generally meets criteria for "exceptional" with minor errors in SOAP formatting or occasional redundant or extraneous information. <BR> Documentation meets criteria for clarity but needs to be better organized.<BR>
Average
Documentation meets criteria for clarity but needs to be better organized.<BR>
Documentation occasionally strays from standard format for SOAP documentation.<BR>
Narratives such as the HPI and Exam occasionally stray from logical sequence but the reader is able to determine findings with minimal difficulty.
Below Average
Documentation does not meet expectations for the graduate level as evidenced by any of the following:<BR>
incorrect formatting, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Score
Identifying information
Exceptional
Includes introductory statement giving an overview of the patient including age, race, gender, reason for presentation.
Above Average
Gives partial description of the patient (3 elements)
Average
Gives partial description (2 elements)
Below Average
Includes HIPPA violation by including protected health information
Score
Education
Exceptional
Education is culturally appropriate, cost effective and manageable, contains components that are manageable for the patient. Caregiver is involved in instruction. Caregiver resources such as education, training, transportation is included.
Above Average
Education is culturally appropriate but unachievable due to various reasons such as access, economics, transportation. Caregiver resources are considered.
Average
Education is not culturally appropriate, is generic and limited to the patient. Caregiver not involved
Below Average
Education is inappropriate to the assessment, is not culturally appropriate and is unachievable.
Score
Subjects:
Medical
Nursing
Types:
Assignment
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