iRubric: Soap Note Grading Rubric

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.

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

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.

Objective assessment is not developed and/or the assessment is inappropriate for the patient's age, gender, and/or inappropriate for the presenting problem.

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>

Plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.

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

Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up.

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.

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>

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.

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.

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.

Education is culturally appropriate but unachievable due to various reasons such as access, economics, transportation. Caregiver resources are considered.

Education is not culturally appropriate, is generic and limited to the patient. Caregiver not involved

Education is inappropriate to the assessment, is not culturally appropriate and is unachievable.