Benchmark clinical soap note
Benchmark - Academic Clinical SOAP Note - Rubric
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Primary or Working Diagnosis (B)
6 points
Criteria Description
Primary or Working Diagnosis (C6.2)
5. Target
6 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.
4. Acceptable
5.4 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided accurately.
3. Approaching
4.8 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is provided.
2. Insufficient
3 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is incomplete or incorrect.
1. Unsatisfactory
0 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is not provided.
Brief Clinical Course (B)
6 points
Criteria Description
Brief Clinical Course (C7.4)
5. Target
6 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation.
4. Acceptable
5.4 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete.
3. Approaching
4.8 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is supported with minor details missing.
2. Insufficient
3 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is only partially supported.
1. Unsatisfactory
0 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is not provided.
Review Of Systems
6 points
Criteria Description
Review Of Systems
5. Target
6 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support.
4. Acceptable
5.4 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with accurate details and support.
3. Approaching
4.8 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided but with minimal detail or support.
2. Insufficient
3 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are incomplete or incorrect.
1. Unsatisfactory
0 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are not present.
Exam
6 points
Criteria Description
Exam
5. Target
6 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support.
4. Acceptable
5.4 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with accurate details and support.
3. Approaching
4.8 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided but with minimal detail or support.
2. Insufficient
3 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are incomplete or incorrect.
1. Unsatisfactory
0 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are not present.
Diagnostics
6 points
Criteria Description
Diagnostics
5. Target
6 points
Diagnostics within the past 24 hours are provided with thorough details and support.
4. Acceptable
5.4 points
Diagnostics within the past 24 hours are provided with accurate details and support.
3. Approaching
4.8 points
Diagnostics within the past 24 hours are provided but with minimal detail or support.
2. Insufficient
3 points
Diagnostics within the past 24 hours are incomplete or incorrect.
1. Unsatisfactory
0 points
Diagnostics within the past 24 hours are not present.
Impression or Assessment
6 points
Criteria Description
Impression or Assessment
5. Target
6 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support.
4. Acceptable
5.4 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with accurate details and support.
3. Approaching
4.8 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided but with minimal detail or support.
2. Insufficient
3 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are incomplete or incorrect.
1. Unsatisfactory
0 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are not present.
Plan (B)
3 points
Criteria Description
Plan (C7.5)
5. Target
3 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support.
4. Acceptable
2.7 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with accurate details and support.
3. Approaching
2.4 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided but with minimal details or support.
2. Insufficient
1.5 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is incomplete or incorrect.
1. Unsatisfactory
0 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is not present.
Geriatric Specific Care
3 points
Criteria Description
Geriatric Specific Care
5. Target
3 points
A discussion of ethical, legal, or geriatric considerations is provided with thorough details and support.
4. Acceptable
2.7 points
A discussion of ethical, legal, or geriatric considerations is provided with accurate details and support.
3. Approaching
2.4 points
A discussion of ethical, legal, or geriatric considerations is provided but with minimal details or support.
2. Insufficient
1.5 points
A discussion of ethical, legal, or geriatric considerations is incomplete or incorrect.
1. Unsatisfactory
0 points
A discussion of ethical, legal, or geriatric considerations is not present.
Mechanics of Writing
6 points
Criteria Description
Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.
5. Target
6 points
No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.
4. Acceptable
5.4 points
Few mechanical errors are present. Suitable language choice and sentence structure are used.
3. Approaching
4.8 points
Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.
2. Insufficient
3 points
Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.
1. Unsatisfactory
0 points
Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout.
Format/Documentation
12 points
Criteria Description
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.
5. Target
12 points
No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.
4. Acceptable
10.8 points
Appropriate format and documentation are used with only minor errors.
3. Approaching
9.6 points
Appropriate format and documentation are used, although there are some obvious errors.
2. Insufficient
6 points
Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.
1. Unsatisfactory
0 points
Appropriate format is not used. No documentation of sources is provided.
Total 60 points