Soap notes

SOAP NOTE RUBRIC

0-5

points

6-10

points

11-15

16-20

points

21-25

points

Student

Score

SUBJ

Data is not organized. Objective is mixed into the subjective data.

Data is not well organized. The complete pre-conceived differential considered is incomplete. Data is missing.

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

Data is well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Little extraneous data may be present.

Complete, concise, relevant without extraneous data. All data needed to support differential is present with no extraneous data.

OBJ

Subjective data is included.

Not all relevant exams were done.

All relevant exams were done but not thoroughly.

All relevant exams were done thoroughly but extraneous exams were also done.

Complete, concise, well-organized and well-written.

DDX

No assessment provided.

Assessment present but mixed with other problems that are not reflective of S/0. Appears to be preceptor's diagnosis.

Assessment reflects information in S/O data but does not include correct differential.

Each problem identified has a differential that is reflected in S/O. Differential/problems are not prioritized correctly.

Assessment and prioritized differential accurate and supported. Demonstrates exceptional critical thinking.

PLAN

No Plan provided

Plan present but does not address all problems identified. Appears to be preceptor’s plan.

Plan addresses all problems but some interventions are not evidence-based.

Plan is organized but fails to address any of: barriers to compliance needs for education plan for preventive complete plan for follow up.

Plan is complete prioritized, and demonstrates exceptional critical thinking. Counseling on despair was accomplished.

Total Score: