DUE 6/2/2023.....PLEASE FOLLOW ALL INSTRUCTIONS......READ ALL ATTACHMENTS

SOAPRUBIC.docx

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SOAP Note Rubric

Key points: SOAP = Subjective; Objective; Assessment; Plan. A common mistake that students make is to combine the ROS (review of systems) with the physical exam. However, the ROS is subjective—what the patient tells you. The PE is objective: your observation through examining the patient. The ROS belongs in the Subjective portion and the PE belongs in the Objective portion of the note. For 693 passing for SOAP notes is 80% or higher.

SOAP Note Rubric

Element	Exceeds Expectations ≥ 90	Meets Expectations 83-89	Partially Meets Expectations 80-82	Does not meet Expectations ≤ 79
SUBJECTIVE
History of Present Illness (HPI) 25%*	Appropriate OLDCARTS all discussed, succinct and complete “Story” of HPI clear and succinct	Appropriate OLDCARTS discussed, extraneous elements included or not succinct	Missing 1-2 pertinent elements	Missing more than 2 pertinent elements
Review of Systems 7.5%	All appropriate systems covered completely, no extraneous	All appropriate systems covered with some extraneous elements	Missing 1 appropriate system	Missing more than 1 appropriate system
Past Medical & surgical History (PMH, PSH) relevant to the HPI Include pertinent history (with positives and negatives) Allergies LMP	Complete problem list of main problems with relevant PMH/PSH to the HPI explored fully Includes pertinent negatives as well	1 element in PMH relevant to HPI missing or not explored fully	2 elements in PMH relevant to the HPI missing	Multiple elements in PMH relevant to the HPI missing
2.5%

Family History (for a focused SOAP, fam hx relevant to the HPI should be explored, a complete list not indicated) 1%	Family history relevant to the HPI included If nothing relevant- can say “Fhx non- contributory”	Family history missing one to two pertinent elements	Family history missing more than two pertinent elements	Not addressed
Social History (for a focused SOAP, social history relevant to the HPI should be explored, a complete list not indicated) 1.5%	Social history relevant to the HPI covered completely	Social history missing one pertinent element	Social history missing 2 or more pertinent elements	Not addressed
OBJECTIVE
Physical Examination (can include diagnostic tests or in clinic tests such as pregnancy test- if applicable)	Appropriate based on complaint with no unrelated exam components	Appropriate based on complaint with some unrelated elements	Missing 2 or less elements or 1 inappropriate exam done	Missing more than 2 elements with more than 1 inappropriate element done
10%
ASSESSMENT
Differential Diagnosis (DDx) and Main Dx for each problem Minimum of 3 differentials diagnosis supported by S + O data and rationale as to why that was or was not chosen for the final Dx	DDX and Main Dx appropriate based on findings with complete reasoning, appropriate ICD-10 and CPT coding for main Dx	Main Dx Appropriate based on findings though missing 1 key DDx Rationale for DDX and main Dx could be better described	Appropriate but possible better one available based on findings or missing some key elements	Inappropriate based on findings
27.5%
PLAN
Treatment Plan for each final diagnosis with diagnostics, referrals, pt education, follow-up parameters	Specific, appropriate and EBP with clear explanations for each Dx-with citations from appropriate sources	Appropriate and EBP, Missing a few elements or explanations not clear for all Dx Missing 1 citation	Appropriate but not first line, or missing multiple minor components Missing > 1 citation	Inappropriate or missing multiple elements Missing citations
(each as needed)
Cite reference for
diagnosis and plan for
each problem.
25%