Progress Note Grading Rubric

NOT NEEDS COMPETENT Excellent (100%)

ACCEPTABLE IMPROVEMENT (85%)
(0%) (70%)

S Reason for Consult Incorrect or missing reason for Correct statement of reason for
consult consult is included.
O (5%)

Subjective/ Inaccurate or irrelevant information is Appropriate, complete & accurate

Objective provided. Data provided does not sub/obj information provided related
Information relate to patient problems. to pertinent problems and drug
therapy.
(10%)

A Assessment of Inaccurate or missing assessment of Incomplete, yet some accurate Appropriate assessment of patient Complete and accurate assessment
Patient Problem(s) the problem(s) and/or current drug assessment of patient problem(s) problem(s) & drug therapy. of patient problem(s) and drug
therapy. Inappropriate or and drug therapy is provided. Includes some extraneous or non- therapy. Written succinctly in
& Drug Therapy
unprofessional terminology. pertinent info professional terminology.
(25%)

Goals of Therapy Inaccurate goals of therapy included. Incomplete, yet some accurate Appropriate goals of therapy Complete list of evidence-based and
Goals of therapy not provided. goals of therapy provided. included. Includes non-patient measurable goals of therapy included
(15%) specific goals. which are patient and disease-state
specific. Written succinctly in
professional terminology.

P Recommended Some or all of drug therapy plan
Drug Therapy missing (missing drug name, route,
dose, or frequency).
(25%)
Inappropriate/inaccurate drug
therapy recommendations.
Treatment plan may result in harm to
the patient.
Complete and reasonable drug
treatment plan included.
Continued/discontinued drug
therapy not appropriately listed.
Drug name(s) misspelled.
Unapproved/inappropriate
abbreviations and/or terminology
present
Complete and reasonable drug
treatment plan included.
Complete and optimal patient and
disease state-specific drug treatment
plan included.
All appropriate preventative and/or
OTC drug therapies included (if
applicable).
Written succinctly in professional
terminology
No unapproved/inappropriate
abbreviations and/or terminology
present.

Monitoring Plan & Incomplete, inaccurate monitoring Some appropriate monitoring Appropriate monitoring parameters All appropriate monitoring parameters
Patient Education parameters and patient education parameters and patient education and patient education points (if and patient education points (if
points (if applicable). points (if applicable) included. applicable) are included. Most applicable) included.
(20%) parameters have a reasonable
Significant extraneous information Optimal frequencies for the
frequency.
included or several parameters monitoring parameters are provided.
without reasonable frequencies
Written succinctly in professional
terminology.

Updated Fall 2022 Sprunger