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
Treatment Goals Less than 50% of problems have appropriate therapeutic goals. Appropriate therapeutic goals for a few identified problems Appropriate therapeutic goals for most identified problems (>80%). Appropriate and relevant therapeutic goals for each identified problem. 3 P Treatment Plan Less than 50% of problems have an appropriate and complete treatment plan. Partially complete and/or inappropriate for a few identified problems information other than “P” provided. Mostly complete and appropriate for each identified problem (>80%). Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem. 5 Counseling, Referral, Monitoring & Follow-up Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan. Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems. Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem. 3 & Header includes: date; course (for modules student name and PID and TA name) OR IPPE/APPE clinical site; patient initials; sex; age; and reason for visit; Format: length does not exceed 1 page font; 1-inch margins). If directions are not followed, deduct ten points from final score. In addition, deduct 10 points (per day) for late submissions. Total Possible Points /100