SOAP Note Scoring Rubric NOT NEEDS COMPETENT EXCELLENT ACCEPTABLE IMPROVEMENT Comments (4 points) (5 points) (0 points) (3 points) Value Score Weight Subjective Less than 50% Poorly organized Well organized; Complete and 2 of pertinent and/or limited partial but concise summary Information information is summary of accurate of pertinent addressed; or is pertinent summary of information. S grossly information pertinent incomplete information information and/or other than (>80%). “S” inaccurate. provided. Objective Less than 50% Poorly organized Partial but Complete and 2 of pertinent and/or limited accurate concise summary Information information is summary of summary of of pertinent addressed; or is pertinent pertinent information. O grossly information information incomplete information (>80%). and/or other than “O” inaccurate. provided. Problem Less than 50% Some problems Most problems Complete 2 of problems are are identified are identified problem list Identification listed; or main (50%-80%); and rationally generated and and problem missed; incomplete or prioritized, rationally Prioritization or problems not inappropriate including the prioritized; no prioritized and/or problem problem extraneous “main” identified prioritization; for the case information or nonexistent includes (>80%). issues listed. problems. nonexistent problems or extraneous A information included. Assessment Less than 50% Assessment is An assessment An optimal and 3 of problems present for is present for thorough of Current include an of problems each problem assessment is Medical appropriate listed but not present for each Condition(s) assessment. optimal problem or Drug Problem
SOAP Note Scoring Rubric NOT ACCEPTABLE (0 points) NEEDS IMPROVEMENT (3 points) COMPETENT (4 points) EXCELLENT (5 points) Score Weight Value Comments S Subjective Information Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate. Poorly organized and/or limited summary of pertinent information information other than “S” provided. Well organized; partial but accurate summary of pertinent information (>80%). Complete and concise summary of pertinent information. 2 O Objective Information Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate. Poorly organized and/or limited summary of pertinent information information other than “O” provided. Partial but accurate summary of pertinent information (>80%). Complete and concise summary of pertinent information. 2 A Problem Identification and Prioritization Less than 50% of problems are listed; or main problem missed; or problems not prioritized and/or identified nonexistent problems. Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included. Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%). Complete problem list generated and rationally prioritized; no extraneous information or issues listed. 2 Assessment of Current Medical Condition(s) or Drug Problem Less than 50% of problems include an appropriate assessment. Assessment is present for of problems An assessment is present for each problem listed but not optimal An optimal and thorough assessment is present for each problem 3
SOAP-Note-Rubric.docx