PSYCH SOAP 1

Grading Rubric for SOAP Notes Updated Course: NSG-535-IKK - Adv Prac in Psych/MH Nurs I

Criteria Unacceptable 0 points

Acceptable 8 points

Good 14 points

Excellent 20 points

Criterion Score

Subjective Data / 20CC is not recorded.

HPI does not reflect

a chronological ac-

count of symptoms

that are sufficiently

descriptive to vali-

date Dx per DSM-5

criteria. Pertinent

negatives are not in-

cluded. The longitu-

dinal course of ill-

ness is nonexistent.

CC is clear. HPI pro-

vides an account of

symptoms that are

descriptive,

nonchronological,

without context,

and do not clearly

validate Dx per

DSM-5 criteria. Few

pertinent negatives

are included. A lon-

gitudinal course of

illness is unclear.

Current medications

are included.

CC is clear, concise

and verbatim from

pt. HPI is thorough

yet concise and pro-

vides a chronologi-

cal account of symp-

toms with some

contextual factors

that are sufficiently

descriptive (oldcarts)

to validate Dx per

DSM-5 criteria.

Pertinent negatives

are included. A lon-

gitudinal course of

illness is apprecia-

ble. Current psychi-

atric medications

and response are

included.

CC is clear, concise

and verbatim from

pt. HPI is thorough

yet concise and pro-

vides a chronologi-

cal account of symp-

toms and contextual

factors that are suf-

ficiently descriptive

(oldcarts) to validate

Dx per DSM-5 crite-

ria. All pertinent

negatives are in-

cluded. A longitudi-

nal course of illness

is clear. Current psy-

chiatric medications

and response are

included.

9/2/26, 6:42 PM Soap Note 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University

https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709130&grpid=0&isprv=0&bp=0&ou=387997 1/6

Criteria Unacceptable 0 points

Acceptable 8 points

Good 14 points

Excellent 20 points

Criterion Score

Objective Data / 20MSE missing most

elements.

MSE contains re-

quired elements.

Is in narrative form

and effectively and

vividly describes the

patient’s presenta-

tion. Concrete ex-

amples of all assess-

ment results are in-

cluded i.e.. “able to

correctly interpret

2/3 simple

proverbs” to validate

documentation of

“abstract thought

intact”.

MSE contains re-

quired elements.

Is in narrative form

and effectively and

vividly describes the

patient’s presenta-

tion. Concrete ex-

amples of all assess-

ment results are in-

cluded i.e.. “able to

correctly interpret

2/3 simple

proverbs” to validate

documentation of

“abstract thought

intact”.

MSE contains re-

quired elements.

Is in narrative form

and effectively and

vividly describes the

patient’s presenta-

tion. Concrete ex-

amples of all assess-

ment results are in-

cluded i.e.. “able to

correctly interpret

2/3 simple

proverbs” to validate

documentation of

“abstract thought

intact”.

9/2/26, 6:42 PM Soap Note 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University

https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709130&grpid=0&isprv=0&bp=0&ou=387997 2/6

Criteria Unacceptable 0 points

Acceptable 8 points

Good 14 points

Excellent 20 points

Criterion Score

Assessment / 20Differential is imper-

tinent to S&S or ab-

sent. Formulation

does not support

nor clearly outline

thought process of

diagnoses.

Diagnoses tendered

are not supported

by criteria in the HPI

description or sub-

stantiated with the

MSE.

Differential is imper-

tinent to S&S, for-

mulation appears

rudimentary and

vague. Diagnoses

are made per DSM-

5 but are marginally

reasonable. Criteria

for diagnoses ten-

dered are not ex-

plicit in the HPI de-

scription or substan-

tiated with the MSE.

Differential is perti-

nent to S&S, formu-

lation contains evi-

dence of critical

thought and subject

knowledge, and rea-

sonable diagnoses

are made per DSM-

5. Clearly met crite-

ria for diagnoses

tendered are explicit

in the HPI descrip-

tion and substanti-

ated with the MSE

Differential is perti-

nent to S&S, formu-

lation contains evi-

dence of critical

thought and subject

knowledge, and rea-

sonable diagnoses

are made per DSM-

5. Clearly met crite-

ria for diagnoses

tendered are explicit

in the HPI descrip-

tion and substanti-

ated with the MSE

9/2/26, 6:42 PM Soap Note 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University

https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709130&grpid=0&isprv=0&bp=0&ou=387997 3/6

Criteria Unacceptable 0 points

Acceptable 8 points

Good 14 points

Excellent 20 points

Criterion Score

Plan / 20Treatment plan is

presented without

sound rationales.

There is no evidence

of synthesis of infor-

mation or critical

thought. Does not

include neurobiol-

ogy of disorder

Evidence-based

treatment plan is

presented with mini-

mal rationales.

Rationales reflect

the student’s mar-

ginal ability to

choose treatments

based not only on

FDA approval or

current evidence

but also the nuances

and unique charac-

teristics of each.

Treatment plan is

reasonable but lacks

comprehensiveness.

There is minimal evi-

dence of synthesis

of information and

critical thought.

Includes limited

neurobiology infor-

mation on the

disorder

Evidence-based

treatment plan is

presented with ra-

tionales. Level of de-

tail reflects the

student’s moderate

ability to choose

treatments based

not only on FDA ap-

proval or current ev-

idence but also the

nuances and unique

characteristics of

each. Treatment

plan is holistic and

comprehensive.

There is some evi-

dence of the

student’s synthesis

of information and

critical thought.

Includes neurobiol-

ogy information on

the disorder

Evidence-based

treatment plan is

presented with de-

tailed rationales.

Level of detail re-

flects the student’s

ability to choose

treatments based

not only on FDA ap-

proval or current ev-

idence but also the

nuances and unique

characteristics of

each. Treatment

plan is holistic and

comprehensive.

There is strong evi-

dence of the

student’s synthesis

of information and

critical thought.

Includes neurobiol-

ogy information on

the disorder

9/2/26, 6:42 PM Soap Note 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University

https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709130&grpid=0&isprv=0&bp=0&ou=387997 4/6

Criteria Unacceptable 0 points

Acceptable 8 points

Good 14 points

Excellent 20 points

Criterion Score

Writing,

Support, APA

/ 20The format is not

consistent with the

example provided in

the course. No re-

cent, scholarly,

peer- reviewed sup-

port of topic.

Substantial gram-

mar, spelling, and

punctuation errors

detracting from the

assignment. Writing

mechanics include

many awkward or

unclear passages

and informal tone

not consistent with

formal scholarly

work. Substantial er-

rors in APA style

based upon the re-

quired APA manuals

listed on the course

syllabi.

The format is

marginally consis-

tent with the exam-

ple provided in the

course. Limited re-

cent (5-7 years),

scholarly, peer- re-

viewed support of

topics. Occasional

spelling, grammar,

and punctuation er-

rors detracting from

the assignment.

Writing mechanics

include awkward or

unclear passages

and informal tone

not always consis-

tent with formal

scholarly work.

Occasional errors in

APA style based

upon the required

APA manuals listed

on the course

syllabi.

The format is fairly

consistent with the

example provided in

the course. Clear,

recent (5-7 years),

scholarly, peer- re-

viewed support of

topics. Minimal

grammar, spelling,

and punctuation er-

rors. Writing me-

chanics include min-

imal awkward or un-

clear passages but

are consistent with

formal scholarly

work. Minimal er-

rors in APA style

manuals listed on

the course syllabi

The format is con-

sistent with the ex-

ample provided in

the course. Strong,

recent (5-7 years),

scholarly, peer- re-

viewed support of

topics. No grammar,

spelling, and punc-

tuation errors.

Writing mechanics

are consistent with

formal scholarly

work. No errors in

APA style based

upon the required

APA manuals listed

on the course

syllabi.

9/2/26, 6:42 PM Soap Note 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University

https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709130&grpid=0&isprv=0&bp=0&ou=387997 5/6

Total / 100

Overall Score

Level 1 0 points minimum

Level 2 5 points minimum

Level 3 8 points minimum

Level 4 11 points minimum

9/2/26, 6:42 PM Soap Note 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University

https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709130&grpid=0&isprv=0&bp=0&ou=387997 6/6