Skip to main content
sign in
Username
Password
forgot?
Sign up
Share
help_outline
help
Pricing
Request Info
Please enable JavaScript on your web browser
menu
iRubric: SOAP Documentation and Patient Chart rubric
find rubric
Your browser does not support iframes.
(draft)
edit
print
share
Copy to my rubrics
Bookmark
test run
assess...
delete
Do more...
SOAP Documentation and Patient Chart
SOAP Documentation and Patient Chart
Appropriate data entry for patient charting
Rubric Code:
F2X6274
By
jjballardhouse
Draft
Public Rubric
Subject:
Medical
Type:
Assessment
Grade Levels:
Graduate
Your browser does not support iframes.
Desktop Mode
Mobile Mode
SOAP component description
Needs Improvement
2.5 pts
Meets Standard
5 pts
Exceeds Standard
10 pts
Subjective
Needs Improvement
Missing significant information about reason for visit. And/or student does not correlate patient's health history information and or interview onto soap notes.
Meets Standard
Minimal data about presenting compalint or reason for visit. Student leaves out a minimum of 2 pertinent items from patient's health history forms, or shared information during the session.
Exceeds Standard
Detailed information describing presenting complaint or reason for visit. Student correlates information found from health history forms, interview and massage session completely.
Objective
Needs Improvement
Absent or significant data omitted from documentation. Student neglects specificity to findings, and or techniques/modalities and or response to treatment is absent or not relational to the subjective information.
Meets Standard
Student is clear on findings during the massage session that correlate to the subjective information, but is techniques/modalities done to treat the objective findings are either not clear or do not appropriately fit, or the student is unclear on the location/duration of the massage, or the response to the treatment is vague.
Exceeds Standard
Detailed information pertaining to findings, match with the techniques/modalities, duration given and the response to treatment matches with the subjective information.
Assessment
Needs Improvement
Student leaves out STG's and/or LTG's or goals are present and do not correlate with the subjective and objective information and/or functional outcomes are absent.
Meets Standard
Student gives appropriate STG's and LTG's based on the subjective and objective findings but functional outcomes are unclear and do not correlate with the health history
Exceeds Standard
Student gives appropriate STG's and LTG's that match the subjective and objective information and gives correct functional outcomes based on their findings along with the health history.
Plan
Needs Improvement
Student leaves out or is unclear of future treatment and or frequency of massages and homework and self-care activities are absent from documentation.
Meets Standard
Student gives appropriate future treatments and frequency of massages yet homework and self-care activities are vague or do not match appropriately with their S,O,A documentation.
Exceeds Standard
Student gives appropriate future treatment and frequency of massages along with beneficial homework and self-care activities that match with the S,O,A sections of their documentation.
Short hand documentation
Needs Improvement
2.5 pts
Fair
5 pts
Excellent
10 pts
Abbreviations
Needs Improvement
Student does not use abbreviations on three or more words where needed.
Fair
Student does not use abbreviations on two or less words.
Excellent
Student clearly writes SOAP notes in abbreviation form where needed.
Legible SOAP documention
Needs Improvement
2.5 pts
Fair
5 pts
Excellent
10 pts
Clearly written
Needs Improvement
Instructor has difficulty reading SOAP notes. or corrections are whited out/scratched out with a pen or correct use of colored pen is not used.
Fair
Student does not use correct spelling in SOAP notes.
Excellent
Student clearly writes out SOAP notes in a clear fashion that is easy to read. Spelling is correct, black pen is used and corrections are crossed out with student initials beside mistake.
Patient Chart
Not Exceptable
0 pts
*
0 pts
Excellent
10 pts
Signature
Not Exceptable
Student does not sign the bottom of patient SOAP notes and Today's Session Plan.
*
Excellent
Student signs the bottom of patient SOAP notes and the Today's session plan.
Organization
Not Exceptable
Patient folders are turned in out of order.
*
Excellent
Student turns in Patient chart in proper documented order.
Consent
Not Exceptable
Student does not properly document consent form with signature and/or initials.
*
Excellent
Student documents review of policies and procedures by proper documentation and signature.
Patient Log List
Not Exceptable
Student does not log their patient list sessions and dates in their turned in their folder, or does not turn in their folder but does complete patient soap notes on time.
*
Excellent
Student submits their folder on time with client list documented inside with date of session.
Student Log List in Patient folder
Not Exceptable
Student does not log their name on the student therapist list in patients folder with date.
*
Excellent
Student documents themselves as the practicing massage therapy student in the log list behind the patients health history form with their name and date.
LATE
0 pts
Enter Title
(N/A)
On Time
50 pts
SOAP notes turned in on time
LATE
Student does not turn in SOAP notes on time.
Enter Title
On Time
Student turns in SOAP notes on time.
Keywords:
Documentation, SOAP note
Subjects:
Medical
Types:
Assessment
Discuss this rubric
You may also be interested in:
More rubrics by this author
More Medical rubrics
More Assessment rubrics
Do more with this rubric:
Preview
Preview this rubric.
Edit
Modify this rubric.
Copy
Make a copy of this rubric and begin editing the copy.
Print
Show a printable version of this rubric.
Categorize
Add this rubric to multiple categories.
Bookmark
Bookmark this rubric for future reference.
Assess
This rubric is still in draft mode and cannot be scored. Please change the rubric status to
ready to use
.
Share
Publish
Link, embed, and showcase your rubrics on your website.
Email
Email this rubric to a friend.
Discuss
Discuss this rubric with other members.
Do more with rubrics than ever imagined possible.
Only with iRubric
tm
.
Copyright © 2024
Reazon Systems, Inc.
All rights reserved.
n98
Your browser does not support iframes.
Your browser does not support iframes.
Your browser does not support iframes.