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iRubric: SOAP Note Rubric

iRubric: SOAP Note Rubric

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SOAP Note Rubric 
SOAP Note Rubric
Rubric to grade a MA SOAP note
Rubric Code: RXB45B6
By dwirth
Ready to use
Public Rubric
Subject: Medical  
Type: Project  
Grade Levels: Undergraduate

Powered by iRubric SOAP Note Rubric
  Unnacceptable 1

(N/A)

Needs Improvement 2

(N/A)

Acceptable 3

(N/A)

Good 4

(N/A)

Excellent 5

(N/A)

Subjective

History of Patient Illness
Unnacceptable 1

Gives no information
Needs Improvement 2
Acceptable 3

Gives small amount of pertinent information or incomplete ideas of the patient.
Good 4
Excellent 5

Provides Chief complaint, any current medications, symptoms, and activities of daily living. This information reflects the true feelings of the patient.
Objective

The section needs to include:<BR>
1. Length of time, where, and for what the client was seen.<BR>
2. Report WHAT YOU SEE (chronologically or by categories)
Unnacceptable 1

Not objective<BR>
No skill OT reflected<BR>
Client is judged<BR>
You write what YOU did.<BR>
Poor grammar and spelling.<BR>
Messy, not professional looking
Needs Improvement 2
Acceptable 3

Do not include measurable skills worked on<BR>
Fair grammar and spelling, therefore although errors are present, note is understandable
Good 4
Excellent 5

All elements present. Excellent grammar, spelling. Very professional
Assessment

Go into each data of the objective section, asking yourself what problems, progress, do you see.<BR>
So what?... Why is this important to the client. Anything that is less than WNL's should be addressed regarding impact on client's performance areas.<BR>
Include education areas.<BR>
End with: CLIENT WILL BENEFIT FROM
Unnacceptable 1

Elements present in the objective section not discussed or new elements discussed which were not mentioned in the Objective.<BR>
Goals do not meet ABCDE criteria<BR>
Poor grammar and spelling.<BR>
Messy, not professional looking
Needs Improvement 2
Acceptable 3

No justification for continued OT or no mention of why client is been discharged.<BR>
Fair grammar and spelling, therefore although errors are present, note is understandable
Good 4
Excellent 5

All elements present. Excellent grammar, spelling. Very professional
Plan

How often will the client be seen and for how long.<BR>
What are you going to be working on, or if client will be discharged.
Unnacceptable 1

Missing two or more elements element<BR>
Goals do not meet ABCDE criteria
Needs Improvement 2
Acceptable 3

Missing one element.<BR>
Fair grammar and spelling, therefore although errors are present, note is understandable
Good 4
Excellent 5

All elements present. Excellent grammar, spelling. Very professional
Use of Correct Terminology

Correct Terminology and Abbreviations will be utilized in documentation
Unnacceptable 1

Missing Terminology<BR>
No abbreviations used<BR>
Incorrect format.
Needs Improvement 2
Acceptable 3

Some terminology was used.<BR>
Some Abbreviations<BR>
was used. Poorly organized.
Good 4
Excellent 5

Uses proper headings and sub-headings. Overall product is easy to read and well organized. Correct Terminology is utilized.



Keywords:
  • SOAP note, medical documentation



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