Soap note rc | Nursing homework help

Soap Note Grading Rubric

This sheet is to help you understand what is required, and what the margin remarks might

be about on your comments of patients. Since most of the comments that you hand in are

uniform, this represents what MUST be included in every write-up.

1) Identifying Data (__5- 5pts): The opening list of the note. It contains age, sex, race, marital

status, etc. The patient complaint should be given in quotes. If the patient has more than

one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in

the subjective and under the appropriate number.

2) Subjective Data (_30__30pts.): This is the historical part of the note. It contains the

following:

a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors that

make it better or worse, and associate manifestations. (10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives

(10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem

(10pts). If more than one chief complaint, each should be written in this manner.

3) Objective Data(_25_25pt.): Vital signs need to be present. Height and Weight should be

included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified

in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes

moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and

normal/abnormal to describe things. (5pts).

4) Assessment (_10__10pts.): All diagnoses should be clearly listed and worded

appropriately with ICD 10 codes. Rationale and Explanation must be evidence based and

have 1-2 in text references to back up you’re reasoning for making your main diagnosis

selection. 3 differential diagnoses must be noted, rationale not required but encouraged.

5) Plan (_15__15pts.): Be sure to include any teaching, health maintenance and counseling

along with the pharmacological and non-pharmacological measures. If you have more than

one diagnosis, it is helpful to have this section divided into separate numbered sections.

Should not be generic information and should be tailored to your patient and their needs /

specific diagnosis.

6) Subjective/ Objective, Assessment and Management and Consistent (__10_10pts.): Does

the note support the appropriate differential diagnosis process? Is there evidence that you

know what systems and what symptoms go with which complaints? The

assessment/diagnoses should be consistent with the subjective section and then the

assessment and plan. The management should be consistent with the assessment/

diagnoses identified.

Clarity of the Write-up(__5_5pts.): Is it literate, organized, and complete?

TOTAL: __100______

Leonardo Trobajo, MSN, APRNP, AGPCNP-BC, AGACNP-BC

CLINICAL INSTRUCTOR:

Professor at MSN/FNP Program