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iRubric: BC- SOAP Grading Rubric

iRubric: BC- SOAP Grading Rubric

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BC- SOAP Grading Rubric 
Soap Note Grading Rubric
Rubric Code: ZXB45B9
By dwirth
Draft
Public Rubric
Subject: Medical  
Type: Assignment  
Grade Levels: Undergraduate

Powered by iRubric BC-SOAP Grading Rubric
Each category will receive a score between 1 and 5. A score of 3 is considered average and represents the expected acceptable level of conduct for that category. If asked, you should be able to provide verification (as written or verbal proof as appropriate) for any score other than "3." If the individual you are evaluating is performing as an entry level provider they should obtain scores of "3" in most categories.
  Unacceptable

Unacceptable - Student does not meet any of the requirements listed in the respective category as defined by an entry level professional.

1 pts

Needs Improvement

Needs Improvement - Student meets some of the requirements listed in the respective category as defined by an entry level professional.

2 pts

Accepatable

Acceptable - Student meets most of the requirements listed in the respective category as defined by an entry level professional.

3 pts

Good

Good - Student meets all of the requirements listed in the respective category as defined by an entry level professional.

4 pts

Excellent

Excellent - Student excels beyond the requirements listed in the respective category as defined by an entry level professional.

5 pts

Subjective Assessment

The student completed comprehensive
patient/bystander interviews. He or she
demonstrated active listening.
Unacceptable

Gives no information with regards to patient complaint. Lacks critical elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.
Needs Improvement

Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient's problem. Irrelevant information predominates subjective assessment.
Accepatable

Subjective assessment is missing 2 elements needed for adequate evaluation of the patient's problem. Includes irrelevant information.
Good

Subjective assessment is missing 1 element needed for adequate evaluation of the patient's problem.
Excellent

Subjective assessment of health status is fully explicated.
Assessment is fully developed and includes location, duration, timing, character, severity provocative/palliative factors and/or other features appropriate for the reason for presentation.
Elements of the PMH that expand on the CC are included.
Objective Assessment

The student completed an appropriate physical
exam.
Unacceptable

Not objective.
No assessment skills reflected.
Client is judged.
You write what YOU did.
Needs Improvement

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

Two or more elements needed for adequate evaluation of a patient's problem is missing from the subjective and/or objective assessment.
Selection of diagnostic tests is inappropriate for CC or is missing when needed.
Good

Objective assessment is missing an element needed for adequate evaluation of the patient's problem.
Includes irrelevant information,
Selection of diagnostic tests is too broad or expensive for evaluating the presenting problem OR
Selection of diagnostic tests is inadequate to address the presenting problem.
Excellent

Objective assessment of health status is fully explicated
Physical exam includes 2 complete sets of vital signs (Minimum), Any relevant developmental data related to assessment of CC (including proper head-to-toe). Appropriate diagnostic tests are performed/ordered.
Assessment/ Diagnoses

The student formulated a clinical/field impression and implemented a treatment plan. Interventions
performed were complete, satisfactory and timely.
Unacceptable

Elements present in the objective section not discussed or new elements discussed which were not mentioned in the Objective. Goals do not meet ABCDE criteria.
Needs Improvement

Lacks differential diagnoses and/or final diagnosis is inappropriate or unacceptable for subjective and objective assessment.
Accepatable

Limited differential diagnoses considered and/or final diagnoses only minimally applicable for subjective and objective assessment.
Good

Minimum of 3 differential diagnoses considered (if realistic/feasible) and appropriate final diagnoses selected for subjective and objective assessment.
Excellent

Greater than 4 appropriate differential diagnoses considered (if realistic/ feasible) and evidence that final diagnoses was determined utilizing evidence-based research as applied to subjective and objective assessments.
Plan of Action/ Overall Management

The student's overall ability to manage and
access the patient at their appropriate level
of training. Was there proper use of terminology and spelling.
Unacceptable

Missing two or more elements element.
Goals do not meet ABCDE criteria. Poor grammar and spelling. Unable to read.
Needs Improvement

Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up. Difficult to read. Poor grammar and spelling
Some terminology was used.
Some Abbreviations
was used. Poorly organized.
Accepatable

Plan is inadequate to fully address the identified problem.expansive or overwhelming for the client or healthcare system OR
Needs to consider alternative features for optimal outcomes. Hand-written with errors. Some terminology was used.
Some abbreviations
were used.
Good

Plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.
Typed/hand-written with minimal spelling errors and/or minimal invalid/confusing abbreviations and easy to read.
Excellent

Plan is appropriate for the diagnosis and accurately addresses the problem identified.
Plan is economically sound.
Plan includes plans for evaluation/follow-up care (as appropriate).
Plan is individualized to the patient's age and development, culture, religion, family, environment, education, and/or any other unique concerns uncovered in assessment. Typed and easy to read, no spelling errors, no confusing or unclear abbreviations.



Keywords:
  • SOAP GRADING RUBRIC FOR EMT-PM STUDENTS

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