iRubric: Soap Note Grading Rubric

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Soap Note Grading Rubric

Rubric designed to evaluate soap notes by graduate SLP students

Rubric Code: QX884X9

By vhammen

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Public Rubric

Subject: Medical

Type: Assignment

Grade Levels: Graduate

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
Assessment	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

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