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iRubric: DARP documentation rubric

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DARP documentation SOAP note documentation rubric for documentation exercise Rubric Code: Q22W7C8 By jmccaffrey2021 Draft Public Rubric Subject: Nursing Type: Assignment Grade Levels: Undergraduate, Graduate

DARP component description
	Needs Improvement 0 pts	Meets Standard 1 pts	Exceeds Standard 2 pts
DATA	Needs Improvement - missing significant information about reason for visit.	Meets Standard - minimal data about presenting compalint or reason for visit.	Exceeds Standard detailed information including objection and subjective data. This may include quotes from client that details the subjective data. Objective data includes vital signs and physical assessment findings
ACTION	Needs Improvement - absent or significant data omitted from documentation	Meets Standard - minimal information present pertinent to client assessment	Exceeds Standard - comtemporaneous documentation with details of nursing actions taken including medications dose/route and contemporaneous timing
RESPONSE	Needs Improvement absent or inappropriate response description	Meets Standard - appropriate response described	Exceeds Standard - contemporaneous documentation that details the client response
Plan	Needs Improvement - absent or inappropriate plan or description of treatment provided.	Meets Standard - appropriate plan or description of treatment provided.	Exceeds Standard - detailed documentation of plan with appropriate future assessments detailed to ensure patient comfort
GRAMMAR	Needs Improvement documentation is not understandable and uses colloquial language instead of acceptable medical terminology	Meets Standard understandable and grammatically correct	Exceeds Standard clear, concise documentation that is grammatically correct and consistently uses correct medical terminology