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SUBJ
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Data is not organized. Objective is mixed into the subjective data.
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Data is not well organized. The complete pre-conceived differential considered is incomplete. Data is missing.
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Data is well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. It is clear to the reader that information is gathered to include/exclude options in the differential. Too much extraneous data
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Data is well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Little extraneous data may be present.
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Complete, concise, relevant without extraneous data. All data needed to support differential is present with no extraneous data.
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OBJ
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Subjective data is included.
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Not all relevant exams were done.
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All relevant exams were done but not thoroughly.
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All relevant exams were done thoroughly but extraneous exams were also done.
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Complete, concise, well-organized and well-written.
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DDX
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No assessment provided.
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Assessment present but mixed with other problems that are not reflective of S/0. Appears to be preceptor's diagnosis.
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Assessment reflects information in S/O data but does not include correct differential.
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Each problem identified has a differential that is reflected in S/O. Differential/problems are not prioritized correctly.
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Assessment and prioritized differential accurate and supported. Demonstrates exceptional critical thinking.
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PLAN
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No Plan provided
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Plan present but does not address all problems identified. Appears to be preceptor’s plan.
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Plan addresses all problems but some interventions are not evidence-based.
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Plan is organized but fails to address any of: barriers to compliance needs for education plan for preventive complete plan for follow up.
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Plan is complete prioritized, and demonstrates exceptional critical thinking. Counseling on despair was accomplished.
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ygalan83
SOAPNOTERUBRIC.docx
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