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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.

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OUTCOME/PERFORMANCE SCORE 0 1 2 3 SCORE COMMENTS
Not Present <50% Documented 50%–100% Documented All Components Documented
Document Organization    

Subjective Structure:

❏Reason for F/U or CC

❏HPI

❏PMH

❏SH/FH

❏Tobacco/EtOH/caffeine/illicit drugs

❏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 guidelines if applicable)

❏ Assessment of whether goals are met

❏ Description of drug therapy 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 to monitor and 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    
Total – / 12  

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

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