iRubric: SOAP note documentation rubric

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SOAP note documentation SOAP note documentation Appropriate data entry for patient charting Rubric Code: Y247X72 By Ms_Sigel_RN Ready to use Public Rubric Subject: Medical Type: Assessment Grade Levels: Graduate

SOAP component description
	Needs Improvement 0 pts	Meets Standard 1 pts	Exceeds Standard 2 pts
Subjective	Needs Improvement - missing significant information about reason for visit.	Meets Standard - minimal data about presenting compalint or reason for visit.	Exceeds Standard - detailed information describing presenting complaint or reason for visit.
Objective	Needs Improvement - absent or significant data omitted from documentation	Meets Standard - minimal information present pertinent to presenting condition or reason for visit.	Exceeds Standard - detailed information pertaining to presenting condition or reason for visit.
Assessment	Needs Improvement - absent or incorrect diagnosis or assessment of patient's condition.	Meets Standard - appropriate diagnosis or assessment of patient's condition.	Exceeds Standard - diagnosis at the highest level of understanding with detailed assessment of patient's condition.
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 and treatment provided.