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iRubric: Soap Note Grading Rubric

iRubric: Soap Note Grading Rubric

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Soap Note Grading Rubric Soap Note Grading Rubric Rubric designed to evaluate soap notes by graduate nursing students Rubric Code: YX9B59W By seeganna Draft Public Rubric Subject: Medical Type: Assignment Grade Levels: (none)

Soap Note Grading Rubric
	Exceptional 4 pts	Above Average 3 pts	Average 2 pts	Below Average 1 pts
Documentation is clear and well org	Exceptional Documentation is clear and well organized.<BR> Appropriate medical terminology is used.<BR> Redundant (repetitious) words, phrases, and other distracting information are omitted.<BR> Format follows a standard. Narratives such as the HPI and Exam have a logical flow.	Above Average Documentation meets criteria for "exceptional" but there is occasional redundant or distracting information. Documentation meets criteria for clarity but needs to be better organized.<BR> Documentation occasionally strays from standard format for SOAP documentation.	Average 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.	Below Average Documentation does not meet expectations for the graduate level as evidenced by either of the following:<BR> lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.
Subjective assessment is fully expl	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 and includes location, duration, timing, character, severity provocative/palliative factors 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 incl	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
Objective assessment is fully expli	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, and any relevant developmental data related to assessment of CC.<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.
Diagnoses are adequate, coherent, a	Exceptional Greater than 5 appropriate differential diagnoses considered and evidence that final diagnoses was determined utilizing evidence-based research as applied to subjective and objective assessments	Above Average Minimum of 5 differential diagnoses considered and appropriate final diagnoses selected for subjective and objective assessment	Average Limited differential diagnoses considered and/or final diagnoses only minimally applicable for subjective and objective assessment	Below Average Lacks differential diagnoses and/or final diagnosis is inappropriate or unacceptable for subjective and objective assessment
Plan is coherent, complete, and afi	Exceptional Plan is appropriate for the diagnosis and accurately addresses the problem identified.<BR> Plan is economically sound.<BR> Plan includes plans for evaluation/follow-up care (as appropriate).<BR> Plan is individualized to the patient's age and development, culture, religion, family, environment, education, and/or any other unique concerns uncovered in assessment.	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.
Evidence-based guidelines utilized	Exceptional Evidence of correct application of evidence-based guidelines without omission to assessment, diagnosis, plan, patient education, or follow-up	Above Average Includes only one minor error in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up	Average Includes 2 or more errors in the application or omission of evidence-based guidelines to assessment, diagnosis, plan, patient education, or follow-up	Below Average Incorrectly or fails to apply evidence-based guidelines to assesment, diagnosis, plan, patient education, or follow-up.

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