Psychiatric SOAP Note Rubric
|
Criteria |
Ratings |
Points |
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|
Chief Complaint (Reason for seeking health care) – S |
4 to >3.0 points Exemplary Includes a direct quote from patient about presenting problem. |
3 to >2.0 points Distinguished Includes a direct quote from patient and other unrelated information. |
2 to >0.0 points Developing Includes information but information is NOT a direct quote. |
0 points Novice Information is completely missing. |
4 points |
|
Demographics – S |
2 points Exemplary Begins with patient initials, age, race, ethnicity, and gender (5 demographics). |
1.5 points Distinguished Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity, and gender). |
1 points Developing Begins with 3 or less patient demographics (patient initials, age, race, ethnicity, and gender). |
0 points Novice Information is completely missing. |
2 points |
|
History of the Present Illness (HPI) – S |
5 to >3.0 points Exemplary Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
3 to >2.0 points Distinguished Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
2 to >1.0 points Developing Includes the presenting problem and 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
1 to >0 points Novice The presenting problem is not clearly stated and/or there are < 4 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity). |
5 points |
|
Allergies – S |
2 points Exemplary Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy). |
1.5 points Distinguished If allergies are present, student does not list each type of drug, environmental factor, herbal, food, latex name and include severity of allergy OR description of the allergy. |
1 points Developing If allergies are present, student only lists the type of allergy and omits the name of the allergy. |
0 points Novice Information is completely missing. |
2 points |
|
Review of Systems (ROS) – S |
5 to >3.0 points Exemplary Includes a minimum of 3 assessments for each body system, assesses at least 9 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
3 to >2.0 points Distinguished Includes 3 or fewer assessments for each body system, assesses 5-8 body systems directed to chief complaint, AND uses the words “admits” and “denies.” |
2 to >0.0 points Developing Includes 3 or fewer assessments for each body system, and assesses less than 5 body systems directed to chief complaint, OR student does not use the words “admits” and “denies.” |
0 points Novice Information is completely missing. |
5 points |
|
Vital Signs – O |
2 points Exemplary Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1.5 points Distinguished Includes at least 6 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
1 points Developing Includes at least 4 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain). |
0 points Novice Information is completely missing. |
2 points |
|
Labs, Diagnostic Tests and Screening Tools – O |
3 points Exemplary During the visit: Includes a list of the labs, diagnostic tests or screening tools reviewed at the visit, values of lab results or screening tools, and highlights abnormal values, OR acknowledges no labs/diagnostic tests were reviewed. |
2 points Distinguished During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit, but does not include the values of lab results or screening tools, but does not highlight abnormal values. |
1 points Developing During the visit: Includes a list of the labs, diagnostic tests, or screening tools reviewed at the visit but does not include the values of the results or highlight abnormal values. |
0 points Novice Information is completely missing. |
3 points |
|
Medications-S |
3 points Exemplary Includes a list of all of the patient reported psychiatric and medical medications and the diagnosis for the medication (including name, dose, route, frequency). |
2 points Distinguished Includes a list of all of the patient reported psychiatric and but omits the medical medications and the diagnosis for the medication (including name, dose, route, frequency). |
1 points Developing Includes a list of some of the patient reported psychiatric and/or medical medications and the diagnosis for the medication (omits the dose, route, frequency of the medications). |
0 points Novice Information is completely missing. |
3 points |
|
Past Medical History-S |
3 points Exemplary Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current. |
2 points Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current. |
1 points Developing Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current. |
0 points Novice Information is completely missing. |
3 points |
|
Past Psychiatric History-S |
4 to >3.0 points Exemplary Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and year of diagnosis. |
3 to >2.0 points Distinguished Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (omits addiction treatment), and year of diagnosis. |
2 to >0.0 points Developing Includes (Outpatient and Hospitalizations), for each psychiatric diagnosis (including addiction treatment), and does not include the year of diagnosis. |
0 points Novice The information is completely missing. |
4 points |
|
Family Psychiatric History-S |
4 to >3.0 points Exemplary Includes an assessment of at least 6 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
3 to >2.0 points Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
2 to >0.0 points Developing Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, mood disorder, bipolar disorder, and history of suicidal attempts. |
0 points Novice Information is completely missing. |
4 points |
|
Social History-S |
3 points Exemplary Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
2 points Distinguished Includes at least 8 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
1 points Developing Includes all 6 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use/pregnancy status, and living situation. |
0 points Novice Information is completely missing. |
3 points |
|
Mental Status Exam-O |
15 to >12.0 points Exemplary Includes all 10 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area. |
12 to >10.0 points Distinguished Includes all 8 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with detailed descriptions for each area. |
10 to >0.0 points Developing Includes >6 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) with some descriptions for each area. |
0 points Novice Includes <3 components of the mental status exam (appearance, attitude/behavior, mood, affect, speech, thought process, thought content/ perception, cognition, insight and judgement) OR detailed descriptions is not included for each area. |
15 points |
|
Primary Diagnoses-A |
11 to >6.0 points Exemplary Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) using the DSM-5-TR. The correct ICD-10 billing code is used. |
6 to >3.0 points Distinguished Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority using the DSM-5-TR. The correct ICD-10 billing code is used. |
3 to >0.0 points Developing Includes an inaccurate diagnosis as the principal diagnosis. The ICD-10 code is incorrect or missing. |
0 points Novice Information is completely missing. |
11 points |
|
Differential Diagnoses-A |
3 points Exemplary Includes at least 2 differential diagnoses that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used. |
2 points Distinguished Includes 1 differential diagnosis that can be supported by the subjective and objective data provided using the DSM-5-TR. The correct ICD-10 billing code is used. |
1 points Developing Includes at least 1 differential diagnosis that is NOT supported by the subjective and objective data. The ICD-10 code is incorrect or missing. |
0 points Novice Information is completely missing. |
3 points |
|
Outcome Labs/Screening Tools – O |
3 points Exemplary After the visit: orders appropriate diagnostic/lab testing or screening tool 100% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.” |
2 points Distinguished After the visit: orders appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing or screening tool clinically required at this time.” |
1 points Developing After the visit, orders appropriate diagnostic testing less than 50% of the time. |
0 points Novice Information is completely missing. |
3 points |
|
Treatment |
10 to >8.0 points Exemplary Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. |
8 to >6.0 points Distinguished Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4-7 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. For non-pharmacological treatment, includes: treatment name, frequency, duration. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is supported by the current US clinical guidelines. |
6 to >0.0 points Developing Includes a detailed pharmacologic and non pharmacological treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following: drug/vitamin/herbal name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. Non-pharmacological treatment NOT included. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. The plan is NOT supported by the current US clinical guidelines OR is unsafe. |
0 points Novice Information is completely missing. |
10 points |
|
Patient/Family Education-P |
5 to >3.0 points Exemplary Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives. |
3 to >2.0 points Distinguished Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives. |
2 to >0.0 points Developing Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives. |
0 points Novice Information is completely missing. |
5 points |
|
Referral |
3 points Exemplary Provides a detailed list of medical and other interdisciplinary referrals or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. |
2 points Distinguished Provides a medical or other interdisciplinary referral or documents NO REFERRAL ADVISED AT THIS TIME. Includes a timeline for follow up appointments. |
1 points Developing Provides a medical or other interdisciplinary referral. DOES NOT include a timeline for follow up appointments. |
0 points Novice Information is completely missing. |
3 points |
|
APA Formatting |
5 to >3.0 points Exemplary Effectively uses literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of precision with APA 7th Edition writing style. |
3 to >2.0 points Distinguished Effectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of precision with APA 7th Edition writing style. |
2 to >0.0 points Developing Ineffectively uses literature and other resources to inform their work. Moderate use of citations and extended referencing. APA 7th Edition writing style not strictly adhered to. |
0 points Novice APA style and writing mechanics not used. |
5 points |
|
References |
5 to >3 points Exemplary The reference page contains at least the required current scholarly academic reference and text reference. Follows APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent and in-text citations. |
3 to >2 points Distinguished References page contains one current scholarly academic resource and text reference. Follows most APA guidelines of components: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations. |
2 to >0 points Developing References page contains one current or outdated scholarly academic resource. Many errors of APA guidelines: double space, 12 pt. font, abstract, level headings, hanging indent, and in-text citations. |
0 points Novice References page contains no current scholarly academic resources, only internet webpages or no reference page. Lack of APA guidelines for references provided or in-text citations. |
5 points |
