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iRubric: SOAP note documentation rubric

iRubric: SOAP note documentation rubric

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

Powered by iRubric 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.



Keywords:
  • Documentation, SOAP note

Subjects:

Types:





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