Soap Note Nurse Practitioner Otitis Externa

6/10/2021 Rubric Assessment - NSG6420-Practicum I: Family Health - Adults & Gerontology CP06 - South University

https://myclasses.southuniversity.edu/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=78101&evalObjectId=392888&evalObjectType… 1/3

NSG6320 Soap Rubric (20 points) Course: NSG6420-Practicum I: Family Health - Adults & Gerontology CP06

/ 4

/ 4

Criteria NOT ACCEPTABLE 0 points

NEEDS IMPROVEMENT 2.5 points

COMPETENT 3.5 points

EXCELLENT 4 points

Criterion Score

Subjective

Information:

“CC”, HPI

:OPQRST IF

f/u: health

status since

last visit,

response to

therapies.

PMH, PSH,

FH, ROS

complete

Objective

Information:

Complete

physical exam

with critical

elements

related to

subjective

data

Less than 50% of

pertinent

information is

addressed; or is

grossly

incomplete

and/or

inaccurate.

Poorly organized

and/or limited

summary of

pertinent

information

(50%-80%);

information

other than “S”

provided

Well organized;

partial but

accurate

summary of

pertinent

information

(>80%).

Complete and

concise summary

of pertinent

information.

Less than 50% of

pertinent

information is

addressed; or is

grossly

incomplete

and/or

inaccurate.

Poorly organized

and/or limited

summary of

pertinent

information

(50%-80%);

information

other than “O”

provided.

Partial but

accurate

summary of

pertinent

information

(>80%).

Complete and

concise summary

of pertinent

information.

6/10/2021 Rubric Assessment - NSG6420-Practicum I: Family Health - Adults & Gerontology CP06 - South University

https://myclasses.southuniversity.edu/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=78101&evalObjectId=392888&evalObjectType… 2/3

/ 4

/ 4

Criteria NOT ACCEPTABLE 0 points

NEEDS IMPROVEMENT 2.5 points

COMPETENT 3.5 points

EXCELLENT 4 points

Criterion Score

Assessment:

Minimum of 3

differentials

supported by

S + O data

Final diagnosis

noted and

optimal and

thorough

subjective and

objective

assessment is

presented for

final

diagnosis.

Plan:

Diagnostic

tests/therapie

s/follow-up,

Patient

education,

health

promotion.

Medications

listed with

dosage/SE/Ed

ucation/

Less than 50% of

diagnoses are

listed; or main

diagnosis missed;

or differential

diagnosis not

prioritized

and/or identified

nonexistent

problems

Some diagnoses

are identified

(50%-80%);

incomplete or

inappropriate

diagnosis

prioritization;

includes

nonexistent

diagnosis or

extraneous

information

included.

Most diagnosis

are identified

and rationally

prioritized,

including the

“main” diagnosis

for the case

(>80%).

Complete

differential

diagnosis

generated and

rationally

prioritized; no

extraneous

information or

issues listed.

Less than 50% of

diagnosis have

an appropriate

and complete

treatment plan.

Less than 50% of

diagnosis include

appropriate

counseling,

monitoring,

referral and/or

follow-up plan.

Partially

complete and/or

inappropriate for

a few identified

diagnosis

(50%-80%);

information

other than “P”

provided.

Patient

education points,

monitoring

parameters,

follow-up plan

and referral plan

(where

applicable) for a

few identified

problems

(50%-80%).

Mostly complete

and appropriate

for each

identified

problem (>80%).

Patient

education points,

monitoring

parameters,

follow-up plan

and referral plan

(where

applicable) for

>80% of

identified

problems.

Specific,

appropriate and

justified

recommendation

s (including drug

name, strength,

route, frequency,

and duration of

therapy) for each

identified

problem. Specific patient

education points,

monitoring

parameters,

follow-up plan

and (where

applicable)

referral plan for

each identified

problem.

6/10/2021 Rubric Assessment - NSG6420-Practicum I: Family Health - Adults & Gerontology CP06 - South University

https://myclasses.southuniversity.edu/d2l/lms/competencies/rubric/rubrics_assessment_results.d2l?ou=78101&evalObjectId=392888&evalObjectType… 3/3

Total / 20

Overall Score

/ 4

Criteria NOT ACCEPTABLE 0 points

NEEDS IMPROVEMENT 2.5 points

COMPETENT 3.5 points

EXCELLENT 4 points

Criterion Score

Analyze

quality and

relevance of S

+ O data and

the evidence

for diagnosis.

Use of clinical

evidence

based

reasoning &

literature in

designing plan

of care,

compare to

plan of care

implemented.

Did not analyze

data gathered.

Did not use

clinical

evidenced based

reasoning.

Did not identify

literature or

treatment

guidelines to

guide plan of

care.

Partially

complete and/or

inappropriate

use of data in

assessment data.

Partially

identified clinical

evidenced based

reasoning.

Partially

identified

literature or

treatment

guidelines to

guide plan of

care.

Mostly complete

and appropriate

analysis of data

in assessment.

General use of

clinical based

reasoning.

Identified

literature in most

part and clinical

guidelines in plan

of care

development

identified.

Analyze quality

and relevance of

S + O data—

supported by

evidence and

clinical

guidelines.

Identify needed

but missing S +

O data. Describe

what you would

do differently

and why.

Use of clinical

evidence based

reasoning &

literature in

designing plan of

care, compare to

the actual plan of

care

implemented

NOT ACCEPTABLE 0 points minimum

NEEDS IMPROVEMENT 12.5 points minimum

COMPETENT 17.5 points minimum

EXCELLENT 20 points minimum