iRubric: SOAP note rubric

Omits documenting where the client was seen and for what reason; documentation is not written chronologically or using categories. Does not specify the task and the assistance required to complete task. Never demonstrated skilled OT services. Never focused on client's response; judgmental. Statements are disorganized; failed to include performance skills or performance areas; measures are inaccurate or fail to reflect professional terminology.

Documents minimally effective where the client was seen and or what reason; documentation is sometimes written chronologically or using categories. Minimally specifies the task and the assistance required to complete task. Occasionally demonstrated skilled OT services. Occasionally focused on client's response.

Documents moderately effective where the client was seen and for what reason; documentation is frequently written chronologically or using categories. Substantially specifies the task and the assistance required to complete task. Frequently demonstrated skilled OT services. Frequently focused on client's response.

Documents highly effective where the client was seen and for what reason; documentation is always written chronologically or using categories. Thoroughly specifies the task and the assistance required to complete task. Always demonstrated skilled OT services. Always focused on client's responses. Avoids being judgmental. Statements address all three: motor, process, and interaction skills in measurable terms. Measures are accurate and depict professional terms.

Ineffectively documents frequency and duration of treatment. Specific and realistic parameters for monitoring and follow-up are rarely present. Never ends with a LTG or STG, whicevher is more appropriate for your client and practice setting. Plan does not support assessment made in previous section. No medical necessity or skilled intervention evident. No thought for next session is given.

Moderately effective documents frequency and duration of treatment. Specific and realistic parameters for monitoring and follow-up are occasionally present. Occasionally ends with a LTG or STG, whichever is more appropriate for your client and practice setting.

Effectively documents frequency and duration of treatment. Specific and realistic parameters for monitoring and follow-up are frequently present. Often ends with a LTG or STG, whichever is more appropriate for your client and practice setting.

Highly effective documents frequency and duration of treatment. Specific and realistic parameters for monitoring and follow-up are always present. Always ends wit a LTG or STG, whichever is more appropriate for your client and practice setting. Plan supports assessment made and overall documented information. Medical necessity and skilled intervention evident. A plan for the next session is given or recommends discharge to evaluating OT.