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SOAP Note Rubric
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Criteria
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Ratings
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Pts
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Demographics
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1 to >0.8 pts
Begins with patient initials, age, race, ethnicity and gender (5 demographics)
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0.8 to >0.25 pts
Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)
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0.25 to >0.0 pts
Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)
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0 pts
Missing criteria and/or submission.
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1 pts
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Chief Complaint (Reason for seeking health care)
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4 to >3.0 pts
Includes a direct quote from patient about presenting problem
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3 to >2.0 pts
Includes a direct quote from patient and other unrelated information
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2 to >0.0 pts
Includes information but information is NOT a direct quote
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0 pts
Missing criteria and/or submission.
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4 pts
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History of the Present Illness (HPI)
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5 to >3.0 pts
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
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3 to >2.0 pts
Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
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2 to >0.0 pts
Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
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0 pts
Missing criteria and/or submission.
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5 pts
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Allergies
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2 to >1.5 pts
Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
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1.5 to >1.0 pts
If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy
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1 to >0.0 pts
If allergies are present, students lists only the type of allergy name
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0 pts
Missing criteria and/or submission.
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2 pts
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Review of Systems (ROS)
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15 to >8.0 pts
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”
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8 to >3.0 pts
Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies”
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3 to >0.0 pts
Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies”
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0 pts
Missing criteria and/or submission.
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15 pts
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Vital Signs
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2 to >1.5 pts
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
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1.5 to >1.0 pts
Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
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1 to >0.0 pts
Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
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0 pts
Missing criteria and/or submission.
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2 pts
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Labs
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2 to >1.5 pts
Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
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1.5 to >1.0 pts
Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.
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1 to >0.0 pts
Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.
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0 pts
Missing criteria and/or submission.
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2 pts
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Medications
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4 to >2.0 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
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2 to >1.0 pts
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency)
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1 to >0.0 pts
Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)
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0 pts
Missing criteria and/or submission.
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4 pts
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Past Medical History
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3 to >2.0 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
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2 to >1.0 pts
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current
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1 to >0.0 pts
Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current
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0 pts
Missing criteria and/or submission.
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3 pts
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Past Surgical History
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3 to >2.0 pts
Includes, for each surgical procedure, the year of procedure and the indication for the procedure
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2 to >1.0 pts
Includes, for each surgical procedure, the year of procedure OR indication of the procedure
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1 to >0.0 pts
Includes, for each surgical procedure but not the year of procedure or indication of the procedure
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0 pts
Missing criteria and/or submission.
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3 pts
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Family History
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3 to >2.0 pts
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
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2 to >1.0 pts
Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
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1 to >0.0 pts
Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
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0 pts
Missing criteria and/or submission.
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3 pts
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Social History
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3 to >2.0 pts
Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
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2 to >1.0 pts
Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
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1 to >0.0 pts
Includes 9 or less of the required information.
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0 pts
Missing criteria and/or submission.
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3 pts
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Health Maintenance / Screenings
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3 to >2.0 pts
Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests
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2 to >1.0 pts
Includes a partial assessment of immunization status and health maintenance needs, missing some key components. Includes an assessment of at least 4 screening tests
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