SOAP NOTE

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Rubric_Print_Format.xlsx

Rubic_Print_Format

Course Code Class Code Assignment Title Total Points
ANP-650 ANP-650-XO0103XB Academic Clinical SOAP Note 65.0
Criteria Percentage Excellent (100.00%)
Content 70.0%
Primary or Working Diagnosis 10.0% 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.
Brief Clinical Course 10.0% 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.
Review Of Systems 10.0% 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.
Exam 10.0% 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.
Diagnostics 10.0% Admission diagnostics are provided with thorough details and support.
Impression or Assessment 10.0% 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.
Plan 5.0% 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.
Geriatric Specific Care 5.0% A discussion of ethical, legal, or geriatric considerations is provided with thorough details and support.
Organization and Effectiveness 10.0%
Mechanics of Writing (includes spelling, punctuation, grammar, language use) 10.0% Writer is clearly in command of standard, written, academic English.
Format 20.0%
Paper Format (Use of appropriate style for the major and assignment) 10.0% All format elements are correct.
Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 10.0% Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.
Total Weightage 100%