SOAP NOTE GRADING RUBRIC
Guidelines:
1-Use the case study in the description to complete the assignment. Fill in the missing details for each
required section that would be expected for the diagnosis.
SUBJECTIVE Analysis (0.2 POINT)
Score received
1-Subjective section should include:
a-Chief complaint (CC)
b-History of present illness (HPI)- All 7
attributes (location, quality, quantity or severity,
timing including onset, frequency, and duration,
setting in which it occurs, aggravating or
relieving factors, and associated symptoms)
c-Past history (Medical, Surgical,
Obstetric/Gynecology, Psychiatric)
d-family history (3 generation pedigree of first-
degree relatives, i.e. parents, siblings, children)
e. Personal and social history (i.e. sexual history
5p’s)
f. Review of systems (ROS, pertinent positives
and/or negatives)
g. Developmentally appropriate-i.e.
developmental history if peds, functional
assessment and/or dementia screen if elderly
a-Identified and collected the necessary data
b-Categorized and organized data using the
appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation and proper billing
code
e- PATIENT’S CULTURE MUST BE NOTED
OBJECTIVE (0.2POINT)
Score received
1-Objective section should include:
a. General survey
b. Vital Signs (including BMI and growth
chart if applicable)
c. All other necessary body systems
d. Diagnostic test if available
a. Identified and collected the necessary data
b. Categorized and organized data using the
appropriate format
c.Incorporated all pertinent data/facts d. Used proper documentation and billing
code
SUBJECTIVE Analysis (0.2 POINT)
Score received
ASSESSMENT (0.2 POINT)
Score received
1- Identified correct diagnosis, ICD-10 code, and
correct differential diagnosis
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data
(e.g., noted trends)
c.Integrated information to arrive at diagnosis
d.Identified risk factors
d. Used proper documentation
PLAN Analysis (0.2POINT)
Score received
a-Recommended an appropriate plan for each
problem
b-Included recommendations for non-drug and
drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included followup & referrals
f- include cultural considerations of patient care
Incorporate the patient's culture on the
demographic section on SOAP notes.
FORMAT (0.2 POINT) Score received
1- APA
2- References Current (atleast two references,
one of which needs to be uptodate and the other
a clinical practice guideline from a peer
reviewed journal article or national organization
such as AAFP, ACOG, USPSTF)
3- Writing clear, concise
4- Summary/Conclusion
TOTAL: /1
SOAP FORMAT & RUBRIC
Initials of Patient:
Patient Age:
Patient Ethnicity:
Initials of Provider:
Clinical Setting:
Patient Status: ____New ____Established
SUBJECTIVE DATA; GRADE RECEIVED: _____
Overall Instructions: 1. Identified and collected the necessary data
2. Categorized and organized data using the appropriate format
3. Incorporated all pertinent data/facts
4. Used proper documentation
5. LIST at the end of your subjective section the billing level : Problem Focused,
Expanded problem focused, detailed, comprehensive (use guidelines for new vs.
established patient
6. Identify cultural influences on care
FORMAT Chief Complaint:
History of Present Illness:
Location
Quality
Quantity or Severity
Timing (Onset, Duration, Frequency)
Setting
Aggravating and relieving Factors
Associated Symptoms
Past history (include dates):
PMH
• Chronic illness (date of onset) & hospitalizations (dates)
Medications: Dose, route, frequency
• Allergies: Medications, Foods, Other Allergens
PSH
• (Dates, indications, and types of operations)
Past Psychiatric Hx
• (Illness and timeframe, diagnosis, hospitalizations and
treatments)
Obstetrical/Gynecological (obstetric history & menstrual history)
Obstetrical History
• (Gravida-Para-TPAL)
Menstrual History
• (Menarche, LMP, PMP, regular/irregular,
frequency, duration, quality of flow, Menopause,
Post-menopausal bleeding, HRT)
Health Promotion/Maintenance: Colonoscopy, Prostate (PSA), BP
check, Cholesterol, Annual Physical, Mammography, PAP, Eye
Exam, Dental etc., Immunizations
Functional Status: ADLs and IADLs
Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk
(ages)
Parents
Siblings
Children
Social History:
Cultural Background
Spiritual History/Religious Affiliation and Practices
Complementary/Alternative Care Practices:
Type of Family (Nuclear, Extended etc.)
Marital Status
Parental Status
Work History
Financial History
Diet
Exercise (Frequency, intensity, Time, Type)
Stress Management
Sleep
Social Support
Sexual history (5ps)
Use of alcohol, smoking, or recreational drugs
Living Arrangements
Travel History
Review of Systems:
Constitutional:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Determine Which LEVEL of HISTORY (Choose one):
Focused HPI (1-3 findings); ROS N.A; PFSH N.A
Expanded HPI (1-3 Findings); ROS 1 or more; PFSH N.A.
Detailed HPI (4 or more findings); ROS 2-9 systems; PFSH one
Comprehensive HPI (4 or more findings or status of 3 or more chronic stable
conditions; ROS 10-14; PFSH 2-3 areas
OBJECTIVE DATA; Grade received_____
Overall Instructions: 1. Identified and collected the necessary data
2. Categorized and organized data using the appropriate format
3. Incorporated all pertinent data/facts
4. Used proper documentation
5. LIST at the end of your subjective section the billing level : Problem Focused,
Expanded problem focused, detailed, comprehensive (use guidelines for new vs.
established patient
FORMAT:
Vital Signs:
Oxygen Saturation:
Ht:
Wt:
BMI:
Constitutional:
General:
Physical Examination:
Head/face:
Eyes:
Ears:
Nose:
Mouth/Throat/ Neck:
Respiratory:
Cardiac:
Breast:
GI:
GU:
GYN (female):
Reproductive (Male):
Musculoskeletal:
Skin/Integument:
Psychiatric:
Neuro:
Hematologic/Lymphatic/Immunologic:
Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):
Focused: 1 body area or organ system (1-5 elements);
Expanded problem focused (2-4 body are or organ system (6-11 elements);
Detailed (5-7 see notes);
Comprehensive (8 organ systems see notes);
Laboratory Data Already Ordered and Available for Review (If not done will go in plan):
Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go
in plan):
ASSESSMENT; GRADE RECEIVED____ 1) Main Diagnosis/Problem:
2) Additional Health Problem/Dx:
3) Differential Diagnoses for top diagnoses
4) Identify Risk Factors
PLAN; GRADE RECEIVED________
For Each Diagnosis or Health Problem Identified as Appropriate:
Additional Laboratory Tests or Diagnostic Data Needed
Pharmacologic Management:
Drug, dose, route, frequency, Disp amount
SIG (write like a prescription)
Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit
etc.
Complementary Therapies:
Health Education:
Referrals:
Follow-up Appointment:
For the Encounter Final Level of Decision Making: (give rationale for level which is based
on Hx, physical, Decision making); Choose one
Straightforward:
Low Complexity:
Moderate Complexity:
High Complexity:
Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems
Reviewed and Level of Physical Exam.
Patient Status: New or established
Level of history
Level of physical (exam)
Level of Medical decision making
- 1-Use the case study in the description to complete the assignment. Fill in the missing details for each required section that would be expected for the diagnosis.