Acute Complaint SOAP Note Grading Rubric

Student name: Rotation: PC1

Points
SOAP note earned/ Comments
available
Subjective (30pts ) /30
CC - (patients CC in quotes) /2
Information should be pertinent to the CC and in SOAP format rather than full H&P. It is acceptable to
state PMH/FMH, etc. as non-contributory/significant as needed. Non-pertinent information should not be
included and may result in points deducted.
HPI /4 (PQRST or OLDCARTS)
PMH /3
FMH /3
Social Hx /3

ROS /4
Organization and flow (information /5
is presented in a logical way and the
most important and pertinent
information is presented first)
The following should be included as a separate heading even if mentioned in the S pertinent to CC.
Meds (including any new or prn /3
meds mentioned in S that patient is
using for their CC)
Allergies (include reaction) /3
Objective (20pts) /20
General statement /3
Vital signs /3
PE findings /14 /10
Lab findings/other tests n/a /4
Assessment (5 pts) /5
Include associated ICD-10 billing
codes
Plan (20 pts) /20
Drug therapy /5 (All notes must include medications.)
Drug name, route, dose,
frequency and length of
therapy
Correct written
prescription included at
end of note
Non-drug therapy /5
Follow-up /5
Patient education /5
General (10 pts) /10
Spelling/Grammar/written to the level /5
of a medical provider
Patient demographics (only patient /5 5 point deduction if patients full name is used
initials are used)/
Student signature & Date included
Diagnostic Rationale (10 pts) /10
Brief reasoning for assessment with
reference to at least 2 quality, peer-

CH/MN Rev 6/17

 reviewed resources
Coding Rationale (5 pts) /5
Brief reasoning for the appropriate
CPT code associated with this
patient encounter
Total /100

Faculty: Date:

CH/MN Rev 6/17