review by rubric and add references
SOAP NOTE RUBRIC
Criteria Points Competent Need Improvement Not Acceptable
Score
Subjective (35 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.
Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient
denies…).
Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.
Chief complaint 5 5 3 1
HPI 10 10 8 6
Relevant PMH & FH 5 5 3 1
ROS 10 10 8 6
Currents: Allergies,
Meds/OTCs, Tobacco,
Immunizations, Diet, Exercise,
Sleep
5 5 3 1
Objective (40 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.
Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient denies)
Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.
General survey (Describe the
state of the patient at the time
of the examination)
10 10 8 6
Vital signs
Height, Weight, BMI
10 10 8 6
Physical exam-systematic,
organized and thorough and
related to the reason of the visit
20 20 18 16
Diagnosis/ Differentials
Diagnosis (10 points)
Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective
assessment and
rationale for
choosing the
Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective assessment
but the rationale for
choosing the
diagnosis is not
Main diagnosis/
Differentials
Diagnosis is not
supported by
the objective
and subjective
assessment and
the rationale for
choosing the
SOAP NOTE RUBRIC
diagnosis is
supported by the
evidence
supported by the
evidence
diagnosis is not
supported by
the evidence
Diagnosis/(Assessment) 5 5 3 1
List of differentials supported
by S+O findings (5 points)
Must provide 3 differential
diagnoses with one citation
for each diagnosis.
5 5 3 1
Plan of care (10 Points) Complete and
appropriate plan
for the main
problem and
other active
problems.
Includes
pharmacologic
and/or non-
pharmacologic
and/or complete
sig components.
Mostly complete and
appropriate plan for
the main problem
and other active
problems. May be
missing appropriate
non-pharmacologic
treatments and/or sig
components.
Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.
Diagnostic
tests/therapies/medications
5 5 3 1
Follow-up/Pt. Education and
Health Promotion
5 5 3 1
References (5 Points) Provides a
complete and
appropriate list of
references that
are in APA
format.
References listed are
appropriate (i.e.
guidelines or
primary), but not
complete and some
may be missing. Not
APA formatted.
References
missing or very
limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.
References 5 5 3 1
Total 100
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