Benchmark – Academic Clinical SOAP Note 1 – Rubric

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Primary or Working Diagnosis

5 points

Criteria Description

Primary or Working Diagnosis

5. Target

5 points

A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.

4. Acceptable

4.5 points

A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided accurately.

3. Approaching

4 points

A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is provided.

2. Insufficient

2.5 points

A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is incomplete or incorrect.

1. Unsatisfactory

0 points

A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is not provided.

Brief Clinical Course

5 points

Criteria Description

Brief Clinical Course

5. Target

5 points

A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation.

4. Acceptable

4.5 points

A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete.

3. Approaching

4 points

A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is supported with minor details missing.

2. Insufficient

2.5 points

A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is only partially supported.

1. Unsatisfactory

0 points

A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is not provided.

Review Of Systems

5 points

Criteria Description

Review Of Systems

5. Target

5 points

Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support.

4. Acceptable

4.5 points

Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with accurate details and support.

3. Approaching

4 points

Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided but with minimal detail or support.

2. Insufficient

2.5 points

Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are incomplete or incorrect.

1. Unsatisfactory

0 points

Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are not present.

Exam

5 points

Criteria Description

Exam

5. Target

5 points

Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support.

4. Acceptable

4.5 points

Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with accurate details and support.

3. Approaching

4 points

Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided but with minimal detail or support.

2. Insufficient

2.5 points

Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are incomplete or incorrect.

1. Unsatisfactory

0 points

Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are not present.

Diagnostics

5 points

Criteria Description

Diagnostics

5. Target

5 points

Diagnostics within the past 24 hours are provided with thorough details and support.

4. Acceptable

4.5 points

Diagnostics within the past 24 hours are provided with accurate details and support.

3. Approaching

4 points

Diagnostics within the past 24 hours are provided but with minimal detail or support.

2. Insufficient

2.5 points

Diagnostics within the past 24 hours are incomplete or incorrect.

1. Unsatisfactory

0 points

Diagnostics within the past 24 hours are not present.

Impression or Assessment

5 points

Criteria Description

Impression or Assessment

5. Target

5 points

Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support.

4. Acceptable

4.5 points

Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with accurate details and support.

3. Approaching

4 points

Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided but with minimal detail or support.

2. Insufficient

2.5 points

Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are incomplete or incorrect.

1. Unsatisfactory

0 points

Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are not present.

Plan (B)

5 points

Criteria Description

Plan (C.7.2)

5. Target

5 points

A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support.

4. Acceptable

4.5 points

A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with accurate details and support.

3. Approaching

4 points

A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided but with minimal details or support.

2. Insufficient

2.5 points

A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is incomplete or incorrect.

1. Unsatisfactory

0 points

A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is not present.

Geriatric Specific Care

5 points

Criteria Description

Geriatric Specific Care

5. Target

5 points

A discussion of ethical, legal, or geriatric considerations is provided with thorough details and support.

4. Acceptable

4.5 points

A discussion of ethical, legal, or geriatric considerations is provided with accurate details and support.

3. Approaching

4 points

A discussion of ethical, legal, or geriatric considerations is provided but with minimal details or support.

2. Insufficient

2.5 points

A discussion of ethical, legal, or geriatric considerations is incomplete or incorrect.

1. Unsatisfactory

0 points

A discussion of ethical, legal, or geriatric considerations is not present.

Mechanics of Writing 

5 points

Criteria Description

Includes spelling, punctuation, grammar, language use.

5. Target

5 points

Writer is clearly in command of standard, written, academic English.

4. Acceptable

4.5 points

Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.

3. Approaching

4 points

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.

2. Insufficient

2.5 points

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

1. Unsatisfactory

0 points

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

Format/Documentation

5 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

5. Target

5 points

No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.

4. Acceptable

4.5 points

Appropriate format and documentation are used with only minor errors.

3. Approaching

4 points

Appropriate format and documentation are used, although there are some obvious errors.

2. Insufficient

2.5 points

Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.

1. Unsatisfactory

0 points

Appropriate format is not used. No documentation of sources is provided.

Total 50 points