|
Criteria
|
Points
|
Competent
|
Need Improvement
|
Not Acceptable
|
Score
|
|
Subjective (35 points)
|
|
Provides complete, concise, and accurate information which is well organized and easy to understand.
|
Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…).
|
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
|
|
|
Chief complaint
|
5
|
5
|
3
|
1
|
|
|
HPI
|
10
|
10
|
8
|
6
|
|
|
Relevant PMH & FH
|
5
|
5
|
3
|
1
|
|
|
ROS
|
10
|
10
|
8
|
6
|
|
|
Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep
|
5
|
5
|
3
|
1
|
|
|
Objective (40 points)
|
|
Provides complete, concise, and accurate information which is well organized and easy to understand.
|
Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies)
|
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
|
|
|
General survey (Describe the state of the patient at the time of the examination)
|
10
|
10
|
8
|
6
|
|
|
Vital signs, wt., BMI
|
10
|
10
|
8
|
6
|
|
|
Physical exam-systematic, organized and thorough and related to the reason of the visit
|
20
|
20
|
18
|
16
|
|
|
Diagnosis/ Differentials Diagnosis (10 points)
|
|
Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the diagnosis is supported by the evidence
|
Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not supported by the evidence
|
Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the diagnosis is not supported by the evidence
|
|
|
Diagnosis/ (Assessment)
|
5
|
5
|
3
|
1
|
|
|
List of differentials supported by S+O findings (5 points)
Must provide 3 differential diagnoses with one citation for each diagnosis.
|
5
|
5
|
3
|
1
|
|
|
Plan of care (10 Points)
|
|
Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic and/or non-pharmacologic and/or complete sig components.
|
Mostly complete and appropriate plan for the main problem and other active problems. May be missing appropriate non-pharmacologic treatments and/or sig components.
|
Missing or inappropriate treatment plan for the main problem and other active problems.
|
|
|
Diagnostic tests/therapies/medications
|
5
|
5
|
3
|
1
|
|
|
Follow-up/Pt. Education and Health Promotion
|
5
|
5
|
3
|
1
|
|
|
References (5 Points)
|
|
Provides a complete and appropriate list of references that are in APA format.
|
References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted.
|
References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant.
|
|
|
References
|
5
|
5
|
3
|
1
|
|
|
Total
|
100
|
|
|
|
|
Casey Celia
Soapnotesrubric11.docx
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