SOAP NOTE RUBRIC
Category Exceptional 3 Satisfactory
Subjective Information is accurate and
complete and is organized and
concise. The documentation is
comprehensive to include all CC,
HPI, PMH, SH, FH, Allergies,
Meds, ROS etc.
Objective Accurate information is
organized and precise and does
not include any major or minor
omission.
Assessment Accurate information provided:
complete and concise
description to include the
diagnosis, supported logically by
subjective and objective data;
cites guidelines as appropriate
Plan Complete and appropriate in
every detail to include
education, further investigation,
follow up, referral (if indicated)
etc.
Overall Appropriate word choice and
grammar / terminology; no grammatical
medical errors; appropriate up to date
terminology scientific references used, for
/ references instance textbooks, clinical
practice guidelines
Adapted from: Barnett, SG. Casey, G. Kopacek, KJ & Porter, AL. (2014). Evaluation of electronic SOAP note grading and feedback. Currents in Pharmacy
Teaching and Learning 6, 516-526.
2 Needs Improvement 1
Accurate information Minor incorrect information and
provided (as in / or information placed in the
exceptional column), but incorrect location; omissions
could be more organized such as allergies, medications
and succinct
Accurate information is Incorrect information, or
provided, but could be contains minor, but important
more organized and information, or incorrect
succinct placement of information is
evident
Accurate information Incorrect information (minor)
provided but could be provided such as drug therapy
more organized inconsistent with established
guidelines; contains problem not
discussed in S and O sections or
information from P section
Appropriate information Missing or inconsistent
(same as exceptional information or using guidelines
column), but with minor that are not appropriate; major
omissions omissions where another
practitioner is unlikely to come
up with the same plan
Few errors with word Incorrect or inappropriate word
choice and terminology; choice or terminology (minor);
fewer than 2 grammatical greater than 3 grammatical
errors; up to date and errors; some sources are
appropriate sources used scientific / or up to date
NS5067P April 2018
Possibly Harmful 0 Score
Major incorrect information and / or
major omissions that make it unlikely
another provider would come to the
same A and P; major omissions such
as HPI, ROS, PMH etc.
Incorrect information (major) or
omissions that make it unlikely
another provider would come to the
same A and P (such as lab results)
Incorrect information (major)
included that could result in wrongly
identified drug therapy which may
result in patient harm
Contains errors that could result in
patient harm; fails to address correct
therapy; has missing or incorrect key
educational points (e.g. drug side
effects), follow up / referral)
Incorrect or inappropriate word
choice or terminology (major); greater
than 5 grammatical errors; few or no
sources are up to date, inappropriate
scientific references
Total (from a possible 15)