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NURSE care

References and please verify with Rubric

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MSNSoapNoteRubricElsaPreceptor.pdf

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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