iRubric: SOAP Note Rubric

Subjective assessment is missing 4 or more critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment

Subjective assessment is missing 3 or more critical elements needed for adequate evaluation of the patient's problem.

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

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

Subjective assessment of health status is fully explicated
CC and HPI are targeted toward the reason for presentation without the inclusion of extraneous information.
CC is succinct.
HPI is fully developed and includes location, duration, timing, character, severity provocative/palliative factors and/or other features appropriate for the reason for presentation.
Elements of the PMH, FH, and ROS that expand on the CC and HPI are included.

Assessment is inappropriate or unacceptable based on subjective AND objective data

Assessment is inappropriate or unacceptable based on subjective OR objective data

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

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

Thorough assessment of the patient. Shows clear understanding of the patients disease states and current conditions.

Documentation does not meet expectations for the P2 level as evidenced by either of the following:
lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.

Documentation does not meet expectations for the P2 level as evidenced by either of the following:
lay terminology, illogical sequencing, and/or missing essential elements.

Documentation needs to be more organized.
Documentation occasionally strays from standard format for SOAP documentation.
Narratives such as the HPI and Exam occasionally stray from logical sequence but the reader is able to determine findings with minimal difficulty.

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.

Documentation is clear and well organized.
Appropriate medical terminology is used.
Redundant (repetitious) words, phrases, and other distracting information are omitted.
Format follows a standard. Narratives such as the HPI and Exam have a logical flow.