Soap Nota Assignment

Criteria

NOT ACCEPTABLE

0 points

NEEDS IMPROVEMENT

0.5 points

COMPETENT

1.5 points

EXCELLENT

2 points

Criterion Score

Subjective Information: “CC”, HPI :OPQRST IF f/u: health status since last visit, response to therapies. PMH, PSH, FH, ROS complete

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.     

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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 “O” provided.

Partial but accurate summary of pertinent information (>80%).

Complete and concise summary of pertinent information.

/ 2

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.

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.

/ 2

Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/

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 recommendations (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.   

/ 2

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

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Rubric Total ScoreTotal

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