iRubric: Soap Note Grading Rubric

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

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.

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

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, any relevant developmental data related to assessment of CC, and objective findings relevant to CC and supporting of Assessment and Plan.<BR>
Appropriate diagnostic tests are performed/ordered.

Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up.

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

Plan is appropriate and meets above criteria but is "generic" rather than individualized to the patient.

Plan is coherent and complete and accurately addresses identified problem(s).<BR> Plan reflects best clinical evidence. <BR> Plan is patient-centered and reflects interprofessional collaboration. <BR>
Plan includes plans for evaluation/follow-up care as appropriate. <BR> Plan is individualized to the patient's age, development, culture, religion, family, environment, education, and psychosocial concerns. <BR> Plan is economically sound. <BR>

Documentation does not meet expectations for the graduate level as evidenced by any of the following:<BR>
incorrect formatting, lay terminology, illogical sequencing, missing essential elements, and/or more than 2 spelling or grammatical errors.

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.

Documentation generally meets criteria for "exceptional" with minor errors in SOAP formatting or occasional redundant or extraneous information. <BR> Documentation meets criteria for clarity but needs to be better organized.<BR>

Documentation is well organized and correctly formatted.<BR>
Language is clear with appropriate medical terminology. <BR>
No redundant, extraneous, or distracting information. <BR>
Narratives have a logical flow.