Comprehensive Final SOAP Note

[SOAP Note Rubric] – 100 Points

Criteria

Exemplary Exceeds Expectations

Advanced Meets Expectations

Intermediate Needs Improvement

Novice Inadequate

Total Points

Subjective – 25% Information about the patient (3 points)

· Name (initials only); age, and gender

· Source of information; note relationship to patient, if relevant

· Reliability of information

Chief Complaint (1 point) History of Presenting Illness (8 points)

· Location

· Quality

· Quantity or severity

· Timing (onset, duration, frequency)

· Setting in which it occurs

· Factors that aggravate or relieve the symptoms

· Associated manifestations

Review of Focus System(s) (5 points) Medications/Allergies (3 points) History (5 points)

· Past Medical History

· Past Surgical History

· Family History

· Social History

· Health Maintenance Practices

Patient described in appropriate detail Concise and clear chief complaint as described by patient HPI includes all components with appropriate detail Comprehensive review of focus system(s) includes pertinent negatives Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted Comprehensive health history is appropriate to reason for visit and includes pertinent negatives 25 points

Patient described in appropriate detail Concise and clear chief complaint as described by patient HPI missing minor detail Comprehensive review of focus system(s) Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted Comprehensive health history is appropriate to reason for visit 22 points

1 detail missed in patient description Chief complaint as described by patient, may not be concise or clear HPI missing 1 component or significant detail Review of focus system missing 1-2 components Medication history missing 1-2 components Health history not appropriate for reason for visit or missing 1-2 components 19 points

>2 details missed in patient description Chief complaint not identified, concise, or clear HPI missing >2 components and significant detail Review of focus system(s) missing >3 components Medication history missing >3 components Health history missing >3 components 17 points

25

Objective – 30% Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points) Appropriate techniques of examination used to identify pertinent findings (10 points)

Appropriate areas and systems included in physical assessment Comprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate 30 points

Missing 1 expected area of assessment Appropriate techniques of examination used but special assessment technique missed 26 points

Missing 2 expected areas of assessment One basic technique of examination missed 23 points

Missing >3 expected areas of assessment >2 techniques of examination missed 20 points

30

Assessment – 20% Differential diagnoses are supported by subjective and objective findings (15 points) Scholarly resources support differential diagnoses (5 points)

Three differential diagnoses are supported by findings and include worst case scenario Rationale for differential diagnoses provided by scholarly resources 20 points

Three differential diagnoses include worst case scenario but one diagnosis may not be fully supported by findings Rationale for differential diagnoses provided by scholarly resources 17 points

Differential diagnoses may or may not include worst case scenario and 2 differential diagnoses not supported by findings Rationale for all differential diagnoses not provided by scholarly resources 15 points

<3 differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst case scenario Scholarly resources not provided or do not support differential diagnoses 13 points

20

Plan – 15% Comprehensive plan to address likely differential diagnosis includes (9 points)

· Diagnostic testing

· Pharmacologic intervention

· Non-pharmacologic intervention

· Referrals

· Patient education

· Follow-up

Plan is supported by appropriate and current practice guidelines (6 points)

Comprehensive plan includes all components Appropriate and current guidelines cited 15 points

Plan missing 1 of the identified components Appropriate and current guidelines cited 13 points

Plan missing 2 of the identified components Guidelines are not current or appropriate for identified problem 12 points

Plan missing >3 of the identified components Guidelines for plan not cited 10 points

15

Documentation – 10% Documentation follows SOAP template, is logical, and in correct format (10 points)

Logical and systematic organization of data Correct terminology, spelling, and grammar Scholarly resources noted in correct APA format 10 points

Logical and systematic organization of data Terminology, spelling, grammar or format errors (1-3) 8 points

Minor errors in organization of data Terminology, spelling, grammar, or format errors (4-5) 7 points

Disorganized flow of data Terminology, spelling, grammar or format errors (>5) 6 points

10

Total Points

100