SOAP Notes

Description

Subjective Information
3 pts

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Level 5

Complete and concise summary of pertinent information.

2 pts

Level 3

Well organized; partial but accurate summary of pertinent information (>80%).

1 pts

Level 1

Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “S” provided.

0 pts

Level 0

Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.

3 pts

This criterion is linked to a Learning OutcomeObjective Information

3 pts

Level 5

Complete and concise summary of pertinent information.

2 pts

Level 3

Partial but accurate summary of pertinent information (>80%).

1 pts

Level 1

Poorly organized and/or limited summary of pertinent information (50%-80%); information other than “O” provided.

0 pts

Level 0

Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Problem Identification and Prioritization

3 pts

Level 5

Complete problem list generated and rationally prioritized; no extraneous information or issues listed.

2 pts

Level 3

Most problems are identified and rationally prioritized, including the “main” problem for the case (>80%).

1 pts

Level 1

Some problems are identified (50%-80%); incomplete or inappropriate problem prioritization; includes nonexistent problems or extraneous information included.

0 pts

Level 0

Less than 50% of problems are listed; or main problem missed; or problems not prioritized and/or identified nonexistent problems.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Assessment of Current Psychiatric & Medical Condition(s) or Drug Therapy-related Problem

3 pts

Level 5

An optimal and thorough assessment is present for each problem.

2 pts

Level 3

An assessment is present for each problem listed but not optimal.

1 pts

Level 1

Assessment is present for 50-80% of problems

0 pts

Level 0

Less than 50% of problems include an appropriate assessment.

3 pts

This criterion is linked to a Learning OutcomeAssessment: Treatment Goals

3 pts

Level 5

Appropriate and relevant therapeutic goals for each identified problem.

2 pts

Level 3

Appropriate therapeutic goals for most identified problems (>80%).

1 pts

Level 1

Appropriate therapeutic goals for a few identified problems (50%-80%).

0 pts

Level 0

Less than 50% of problems have appropriate therapeutic goals.

3 pts

This criterion is linked to a Learning OutcomePlan: Treatment Plan

3 pts

Level 5

Specific, appropriate and justified recommendations (including drug name, strength, route, frequency, and duration of therapy) for each identified problem.

2 pts

Level 3

Mostly complete and appropriate for each identified problem (>80%).

1 pts

Level 1

Partially complete and/or inappropriate for a few identified problems (50%-80%); information other than “P” provided.

0 pts

Level 0

Less than 50% of problems have an appropriate and complete treatment plan.

3 pts

This criterion is linked to a Learning OutcomePlan: Counseling, Referral, Monitoring & Follow-up

2 pts

Level 5

Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.

1 pts

Level 3

Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.

0.5 pts

Level 1

Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).

0 pts

Level 0

Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.

2 pts

Total Points: 20

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