PMHNP– SOAP Note Rubric
|
Criteria |
Ratings |
Pts |
|||
|
S (Subjective) |
10 points Accomplished Symptom analysis is well organized in a SOAP format, with C/C, Past Psychiatric Hx, Social Hx, and other pertinent past and current diagnostic details. SOAP Note is complete, concise, relevant with no extraneous data. |
6 points Satisfactory Symptom analysis is well organized in a SOAP format, with C/C, Past Psychiatric Hx, Social Hx, and other pertinent past and current diagnostic details. Some extraneous data present with 1 minor data point missing. |
4 points Needs Improvement Symptom analysis is not well organized or presented in a varied format. Required data is missing. There is too much extraneous data present or 2-3 minor data points are missing. |
0 points Unsatisfactory Symptom analysis is inadequate and is not organized. Objective or other data is mixed into the subjective data. Important data is missing. |
10 pts |
|
O (Objective) |
10 points Accomplished Mental Status Exam is complete, concise, well-organized, and well-written. Includes pertinent psychiatric information. Organized by MSE list format. No extraneous information is included. |
6 points Satisfactory Mental Status Exam is partially incomplete, organized, and satisfactorily written. Includes pertinent psychiatric information with additional extraneous information included. Somewhat organized in MSE list format. |
4 points Needs Improvement Mental Status Exam is incomplete, loosely organized with improvements required. Relevant psychiatric information is omitted. |
0 points Unsatisfactory Mental Status Exam is absent, disorganized in presentation, adheres to no specific format, or grossly omits relevant or pertinent psychiatric information. |
10 pts |
|
A (Assessment) |
10 points Accomplished Diagnosis and Differential Dx are correct with DSM-5 code(s) and supported by subjective and objective data. Includes: 1 working Dx and 2 Differential Dx. |
6 points Satisfactory Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data. Missing at least one (1) pertinent differential diagnosis not listed according to subjective and objective data. Working diagnosis is correct. |
4 points Needs Improvement Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data. Missing up to two (2) pertinent differential diagnoses based on subjective and objective data presented. Or differential diagnoses are adequate with an incorrect working diagnosis. |
0 points Unsatisfactory All diagnoses (working diagnosis and differential diagnoses) are incorrect or is missing based on the subjective and objective data presented. |
10 pts |
|
P (Plan) |
10 points Accomplished Plan is well-organized, complete, evidence-based, and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient. *Plan requirements: prescribed medications, if any; explanation of off-label medication use, if prescribed; risks and benefits of medications identified; therapy recommendations; patient education; referral/follow-up; and health maintenance. |
6 points Satisfactory Plan is organized, complete, evidence-based and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient. Plan is missing 1-2 of the required items. |
4 points Needs Improvement Plan is less organized, is not based on evidence. Fails to address each diagnosis sufficiently or is not individualized or patient-centric Plan is missing more than 2 of the required items. |
0 points Unsatisfactory Plan is disorganized, absent, or is missing all the required items. |
10 pts |
|
Total |
40 pts |
