Soap Note 1
cindyrod14
STUFNPSOAPNoteRubric2.pdf
D istinguised
E xcellent
F air
P oor
Includes a direct quote from patient about
presenting problem Includes a direct quote from
patient and other unrelated inform
ation Includes inform
ation but inform ation is N
O T
a direct quote
Inform ation is com
pletely m issing
4 P oints
3 P oints
2 P oints
0 P oints
B egins w
ith patient initials, age, race, ethnicity and gender (5 dem
ographics) B
egins w ith 4 of the 5 patient dem
ographics (patient initials, age, race, ethnicity and gender)
B egins w
ith 3 or less patient dem ographics
(patient initials, age, race, ethnicity and gender) Inform
ation is com pletely m
issing
2 P oints
1.5 P oints
1 P oints
0 P oints
Includes the presenting problem and the 8
dim ensions of the problem
(O LD
C A
R T
S – O
nset, Location, D uration, C
haracter, A
ggravating factors, R elieving factors,
T im
ing and Severity)
Includes the presenting problem and 7 of the 8
dim ensions of the problem
(O LD
C A
R T
S – O
nset, Location, D uration, C
haracter, A
ggravating factors, R elieving factors, T
im ing
and Severity)
Includes the presenting problem and 6 of the 8
dim ensions of the problem
(O LD
C A
R T
S – O
nset, Location, D uration, C
haracter, A
ggravating factors, R elieving factors, T
im ing
and Severity)
Inform ation is com
pletely m issing
5 P oints
3 P oints
2 P oints
0 P oints
Includes N K
A (including = D
rug, E
nvironem ental, Food, H
erbal, and/or Latex or if allergies are present (reports for each
severity of allergy A N
D description of
allergy)
If allergies are present, students lists type D rug,
environem tal factor, herbal, food, latex nam
e and includes severity of allergy O
R description of
allergy
If allergies are present, students lists only the type of allergy nam
e Inform
ation is com pletely m
issing
2 P oints
1.5 P oints
1 P oints
0 P oints
Includes a m inim
um of 3 assessm
ents for each body system
and assesses at least 9 body system
s directed to chief com plaint
A N
D uses the w
ords “adm its” and “denies”
Includes 3 or few er assessm
ents for each body system
and assesses 5-8 body system s directed to
chief com plaint A
N D
uses the w ords “adm
its” and “denies”
Includes 3 or few er assessm
ents for each body system
and assesses less than 5 body system s
directed to chief com plaint O
R student does not
use the w ords “adm
its” and “denies”
Inform ation is com
pletely m issing
12 P oints
6 P oints
3 P oints
0 P oints
Includes all 8 vital signs, (B P (w
ith patient position), H
R , R
R , tem
perature (w ith
Fahrenheit or C elsius and route of
tem perature collection), w
eight, height, B M
I (or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (B P (w
ith patient position), H
R , R
R , tem
perature (w ith Fahrenheit or C
elsius and route of tem
perature collection), w eight,
height, B M
I (or percentiles for pediatric population) and pain.)
Includes 6 or less vital signs, (B P (w
ith patient position), H
R , R
R , tem
perature (w ith Fahrenheit
or C elsius and route of tem
perature collection), w
eight, height, B M
I (or percentiles for pediatric population) and pain.)
Inform ation is com
pletely m issing
2 P oints
1.5 P oints
1 P oints
0 P oints
Includes a list of the labs review ed at the
visit, values of lab results and highlights abnorm
al values O R
acknow ledges no
labs/diagnostic tests w ere review
ed.
Includes a list of the labs review ed at the visit,
values of lab results but does not highlight abnorm
al values.
Includes a list of the labs review ed at the visit but
does not include the values of lab results or highlight abnorm
al values. Inform
ation is com pletely m
issing
3 P oints
2 P oints
1 P oints
0 P oints
Includes a list of all of the patient reported m
edications and the m edical diagnosis for
the m edication (including nam
e, dose, route, frequency)
Includes a list of all of the patient reported m
edications and the m edical diagnosis for the
m edication (including 3 of the 4: nam
e, dose, m
edications route, frequency)
Includes a list of all of the patient reported m
edications (including 2 of the 4: nam e, dose,
route, frequency) Inform
ation is com pletely m
issing
Subjective
O bjective
M edications
Labs
R eview
of System s (R
O S)
H istory of the P
resent Illness (H P
I)
D em
ographics
C hief C
om plaint (R
eason for seeking health care)
A llergies
V ital Signs
4 P oints
2 P oints
1 P oints
0 P oints
Includes an assessm ent of at least 5
screening tests Includes an assessm
ent of at least 4 screening tests
Includes an assessm ent of at least 3 screening tests
Inform ation is com
pletely m issing
3 P oints
2 P oints
1 P oints
0 P oints
Includes (M ajor/C
hronic, T raum
a, H
ospitaliztions), for each m edical diagnosis,
year of diagnosis and w hether the diagnosis
is active or current
Includes (M ajor/C
hronic, T raum
a, H
ospitaliztions), for each m edical diagnosis,
either year of diagnosis O R
w hether the diagnosis
is active or current
Includes each m edical diagnosis but does not
include year of diagnosis or w hether the
diagnosis is active or current Inform
ation is com pletely m
issing
3 P oints
2 P oints
1 P oints
0 P oints
Includes, for each surgical procedure, the year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of procedure O
R indication of the procedure
Includes, for each surgical procedure but not the year of procedure or indication of the procedure
Inform ation is com
pletely m issing
3 P oints
2 P oints
1 P oints
0 P oints
Includes an assessm ent of at least 4 fam
ily m
em bers regarding, at a m
inim um
, genetic disorders, diabetes, heart disease and
cancer.
Includes an assessm ent of at least 3 fam
ily m
em bers regarding, at a m
inim um
, genetic disorders, diabetes, heart disease and cancer.
Includes an assessm ent of at least 2 fam
ily m
em bers regarding, at a m
inim um
, genetic disorders, diabetes, heart disease and cancer.
Inform ation is com
pletely m issing
3 P oints
2 P oints
1 P oints
0 P oints
Includes all of the follow ing: tobacco use,
drug use, alcohol use, m arital status,
em ploym
ent status, current/previous occupation, sexual orientation, sexually
active, contraceptive use, and living situation.
Includes 10 of the 11 follow ing: tobacco use,
drug use, alcohol use, m arital status, em
ploym ent
status, current/previous occupation, sexual orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less of the follow ing: tobacco use,
drug use, alcohol use, m arital status, em
ploym ent
status, current/previous occupation, sexual orientation, sexually active, contraceptive use,
and living situation.
Inform ation is com
pletely m issing
3 P oints
2 P oints
1 P oints
0 P oints
Includes a m inim
um of 4 assessm
ents for each body system
and assesses at least 5 body system
s directed to chief com plaint
Includes a m inim
um of 3 assessm
ents for each body system
and assesses at least 4 body system s
directed to chief com plaint
Includes a m inim
um of 2 assessm
ents for each body system
and assesses at least 4 body system s
directed to chief com plaint
Inform ation is com
pletely m issing
12 P oints
6 P oints
3 P oints
0 P oints
Includes a clear outline of the accurate principal diagnosis A
N D
lists the rem aining
diagnoses addressed at the visit (in descending priority)
Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal diagnosis
Inform ation is com
pletely m issing
5 P oints
3 P oints
2 P oints
0 P oints
Includes at least 3 differential diagnoses for the principal diagnosis
Includes 2 differential diagnoses for the principal diagnosis
Includes 1 differential diagnosis for the principal diagnosis
Inform ation is com
pletely m issing
5 P oints
3 P oints
2 P oints
0 P oints
D iagnosis
A ssessm
ent
P lan
F am
ily H istory
Screenings
P ast M
edical H istory
D ifferential D
iagnosis
Social H istory
P ast Surgical H
istory
P hysical E
xam ination
Includes a detailed pharm acologic treatm
ent plan for each of the diagnoses listed under “assessm
ent”. T he plan includes A
LL of the follow
ing: drug nam e, dose, route,
frequency, duration and cost as w ell as
education related to pharm acologic agent. If
the diagnosis is a chronic problem , student
includes instructions on currently prescribed m
edications as above.
Includes a detailed pharm acologic treatm
ent plan for each of the diagnoses listed under
“assessm ent”. T
he plan includes 4 of the follow
ing 7: the drug nam e, dose, route,
frequency, duration and cost as w ell as education
related to pharm acologic agent. If the diagnosis is
a chronic problem , student includes instructions
on currently prescribed m edications as above.
Includes a detailed pharm acologic treatm
ent plan for each of the diagnoses listed under
“assessm ent”. T
he plan includes less than 4 of the follow
ing: the drug nam e, dose, route,
frequency, duration and cost as w ell as education
related to pharm acologic agent. If the diagnosis
is a chronic problem , student includes
instructions on currently prescribed m edications
as above.
Inform ation is com
pletely m issing
5 P oints
3 P oints
2 P oints
0 P oints
Includes appropriate diagnostic/lab testing 100%
of the tim e O
R acknow
ledges “no diagnostic testing clinically required at this
tim e”
Includes appropriate diagnostic/lab testing 50%
of the tim e O
R acknow
ledges “no diagnostic testing clinically required at this tim
e”
Includes appropriate diagnostic testing less than 50%
of the tim e.
Inform ation is com
pletely m issing
5 P oints
3 P oints
2 P oints
0 P oints
Includes at least 3 strategies to prom ote and
develop skills for m anaging their illness and
at least 3 self-m anagem
ent m ethods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to prom ote and
develop skills for m anaging their illness and at
least 2 self-m anagem
ent m ethods on how
to incorporate healthy behaviors into their lives.
Includes at least 1 strategies to prom ote and
develop skills for m anaging their illness and at
least 1 self-m anagem
ent m ethods on how
to incorporate healthy behaviors into their lives.
Inform ation is com
pletely m issing
5 P oints
3 P oints
2 P oints
0 P oints
Includes at least 3 prim ary prevention
strategies (related to age/condition (i.e. im
m unizations, pediatric and pre-natal
m ilestone anticipatory guidance)) and at
least 2 secondary prevention strategies (related to age/condition (i.e. screening))
Includes at least 2 prim ary prevention strategies
(related to age/condition (i.e. im m
unizations, pediatric and pre-natal m
ilestone anticipatory guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e. screening))
Includes at least 1 prim ary prevention strategies
(related to age/condition (i.e. im m
unizations, pediatric and pre-natal m
ilestone anticipatory guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e. screening))
Inform ation is com
pletely m issing
4 P oints
2 P oints
1 P oints
0 P oints
Includes recom m
endation for follow up,
including tim e fram
e (i.e. x # of days/w
eeks/m onths)
Includes recom m
endation for follow up, but does
not include tim e fram
e (i.e. x # of days/w
eeks/m onths)
D oes not include follow
up plan
4 P oints
2 P oints
0 P oints
0 P oints
H igh level of A
PA precision
M oderate level of A
PA precision
Incorrect A PA
style Inform
ation is com pletely m
issing
3 P oints
2 P oints
1 P oints
0 P oints
Free of gram m
ar and spelling errors W
riting m echanics need m
ore precision and attention to detail
W riting m
echanics need serious attention
3 P oints
2 P oints
0 P oints
0 P oints
P harm
acologic treatm ent plan
F ollow
up plan
W riting
G ram
m ar
R eferences
D iagnostic/Lab Testing
A nticipatory G
uidance
E ducation
