Skip to Main Content

| Download (.pdf) | Print
SOAP Note Rubric
The aim of this rubric is to guide students in understanding what components should be in a SOAP note and the general structure and format recognized by the majority of medical practitioners to facilitate succinct and accurate patient information for care.
OUTCOME/PERFORMANCE SCORE

0

Not Present

1

<50% Documented

2

B/N 50-100% Documented

3

All Components Documented

SCORE COMMENTS
Document Organization

Subjective Structure

  • Reason for F/U or CC

  • HPI

  • PMH

  • SH/FH

  • Tobacco/EtOH/Caffeine/ Illicit Medications

  • Allergies/ADRs

(PPCP: Collect)

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked

Objective Structure

  • Medication List (Drug | Dose | Route)

  • PE

  • ROS

  • VS

  • Diagnostic Testing

  • Lab Values

(PPCP: Collect)

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked

Assessment Structure

  • Goal(s) of therapy (per guideline if applicable)

  • Assessment of whether goals are met

  • Description of disease state problem(s) if present

  • Brief alternatives and rationale

(PPCP: Assessment)

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked

Plan Structure

  • Discontinued, changed, and new therapy(s) documented (Drug, dose, route, frequency, duration)

  • Education provided

  • Monitoring and Follow-up (What, when, and what patient should do, next visit(s))

(PPCP: Implement/Follow-Up)

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked
Patient Assessment (Clinical Accuracy Assessed)

Problem Identification

  • Interprets data and identifies all High and Medium priority problems (eg, High priority problems are urgent; Medium priority problems need to be addressed during this encounter; Low priority problems can be addressed at next visit)

  • Ranks problems in order of decreasing priority accurately and able to provide rationale if asked

  • Makes it clear to reader when a drug is not meeting a safety or efficacy goal

(PPCP: Assess)

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked
Pharmacotherapy Plan (Clinical Accuracy Assessed)

Goals of Therapy for the High Priority Problem(s) are Accurate

  • Identified

  • Complete

  • Patient Specific

(PPCP: Assess)

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked

Plan: Accurately and completely designs or alters patient specific pharmacotherapy plan for the high priority problem

  • Discontinued therapy (drug, dose, frequency, duration)

  • Changed therapy (drug, dose, frequency, duration)

  • New therapy (drug, dose, frequency, duration)

  • Patient education provided (drug, dose, frequency, duration)

(PPCP: Plan/Implementation))

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked

Monitoring: Includes monitoring plan that is accurate and complete

  • Safety parameters

  • Efficacy parameters

  • Drug specific

  • Patient specific

  • Timeline specific

(PPCP: Follow-Up)

0% of Items Checked <50% of Items Checked <100% but >50% of Items Checked 100% of Items Checked
Total Points
Total Points/ Max Points (12)
Final Grade (out of 100%)

*Rubric was created by Dr. Michael Bear and Dr. Timothy Aungst.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.