2014 Integrated Problem Solving SOAP Rubric

2014 Integrated Problem Solving SOAP Rubric

Subjective Elements / Exemplary / Proficient / Needs Improvement / Significant Deficiency
□ CC □ HPI
□ PMHx □ FH
□ SH □ ROS / □ All relevant items complete and pertinent to support their A/P, in their own words
□ Complete sentences, tells a story / □ Most relevant items complete and pertinent in their own words / □ Some relevant items complete and pertinent in their own words / □ Missing one or more item(s) necessary to support the A/P
□ Information cut/pasted from case (Plagiarism)
□ Falsifying data
ObjectiveElements / Exemplary / Proficient / Needs Improvement / Significant Deficiency
□ Medications
- generic (Brand) - dose
- route - frequency
□ Allergies/Adverse Events
- Offending agent
- Reaction
□ Pertinent labs / diagnostic tests
□ Vital signs
□ Rating scales (ex pain, psychiatric etc.) / □ All relevant items complete and pertinent to support their A/P / □ Most relevant items complete
□ Most items pertinent
□ Some items included that are not pertinent / □ Some relevant items complete
□ Some items pertinent
□ Most items included that are not pertinent / □ Missing one or more item(s) necessary to support the A/P
□ Falsifying data
Assessment Elements
& Treatment Goals / Exemplary / Proficient / Needs Improvement / Significant Deficiency
□ ALL problems listed
-New / Previously identified medical
problems
-Drug-related problems included and identified by disease state not DRP language
□ ALL problems have treatment goals
-Medication
-Non-drug therapy/lifestyle
-Etc.
□ ALL problems are accurately assessed
- Controlled/Uncontrolled
- Adherent/Non-adherent
-Justification for therapy decision
□ Primary or most urgent problem correctly identified as such
□ Secondary or less urgent problems are prioritized in a patient-specific manner
□ Evidence-based (supported by primary literature and /or current guidelines) / □ All problems listed, accurately assessed, and appropriately prioritized
□ All problems have complete treatment goals
□ All assessments supported by evidence based medicine / □ Most problems listed
□ Most problems accurately assessed
□ All problems appropriately prioritized
□ Most problems have treatment goals
□ Most recommendations are evidenced based when available / □ Some problems listed □ Some problems accurately assessed
□ Primarily problem not appropriately prioritized
□ Some problems have treatment goals
□ Some / no recommendations are evidenced based when available
□ DRP language used that is not collaborative / □ Primary problem not addressed
□ Significant error made in assessment that could potentially cause patient harm
Plan Elements / Exemplary
(3 points) / Proficient
(2 points) / Needs Improvement
(1 point) / Significant Deficiency
(0 points)
□ Problem listed in assessment matches the planned actions in this section
□ Medications/OTC Recommendations
- generic (Brand)
- Appropriate dose, route,
frequency, duration, administration
- If IV: dilution/ infusion rates
□ *Non-medication Recommendations
- Lifestyle recommendations
- Procedures
- Quality of life impact
- Medical, social, cultural, and ethical recommendations (as applicable)
□ Patient Counseling
- Key patient counseling/education (administration, warnings, most common and/or severe side effects) on new or adjusted medications as applicable to setting (inpatient vs. ambulatory care)
-Adherence recommendations
□ Monitoring
- Drug monitoring (for each drug)
- Disease state monitoring (for each
disease state)
- Includes specific labs to monitor and
frequency of monitoring
□ Follow-up
- Patient follow-up appointments for each problem/disease state as applicable to setting (inpatient vs ambulatory care)
□ Recommendations are safe, effective and routinely accepted in practice
*You will need to address lifestyle recommendations for every patient problem, as applicable / □ All problems match those listed in the assessment section
□ All medication/OTC recommendations are complete
□ All non-medication recommendations are complete as appropriate
□ All patient counseling points included for new or adjusted medications
□ All monitoring parameters included for each drug and disease state and include lab orders, values to be monitored and frequency of monitoring
□ Follow-up is included for all problems/disease states
□ All recommendations are safe, effective and routinely accepted in practice / □ Most problems match those listed in the assessment section
□ Most medication/OTC recommendations are complete
□ Most non-medication recommendations are complete as appropriate
□ Most patient counseling points included for new or adjusted medications
□ Most monitoring parameters included for each drug and disease state and include lab orders, values to be monitored and frequency of monitoring
□ Follow-up is included for most problems/disease states
□ Most recommendations are safe, effective and routinely accepted in practice / □ Some problems match those listed in the assessment section
□ Some medication/OTC recommendations are complete
□ Some non-medication recommendations are complete as appropriate
□ Some patient counseling points included for new or adjusted medications
□ Some monitoring parameters included for each drug and disease state and include lab orders, values to be monitored and frequency of monitoring
□ Follow-up is included for some problems /disease states
□ Some recommendations are safe, effective and routinely accepted in practice / □ A recommendation is made which is a “fatal flaw” or would cause significant harm to a patient
Construction / Organization / Exemplary / Proficient / Needs Improvement / Significant Deficiency
□ Note construction
- Organized, effective, clear and concise
- Appropriate grammar and free of spelling errors
□ Medical abbreviations/terminology/language
- Professional, appropriate, and courteous
*(Ex. “I recommend that the patient discontinue metformin therapy” NOT “Someone needs to discontinue the metformin”)
**(e.g., AVOID use of “SHOULD”).
*** (e.g., (qd, U (UNITS), qod, etc)
□ References
- Appropriate references utilized
-Appropriate citation format / □ Construction of SOAP note is organized, effective, clear and concise.
□ All medical abbreviations/terminology/language used correctly, professional and courteous*
□ All information in appropriate sections
□ Little to no (0-1) misspellings and/ or grammatical errors
□ NO use of unapproved medical abbreviations
□ Included references are appropriately cited (i.e. guidelines, studies) / □ Construction of SOAP note is organized and effective, and fairly concise
□ Most medical abbreviations/ terminology/ language used correctly and professionally
□ few (2-3) misspellings and/or inappropriate abbreviation or terminology
□ References are included but are not cited properly. / □ Construction of SOAP note is disorganized, no clear direction or structure, not concise.
□ SOAP note uses inappropriately judgmentallanguage or vague terminology
□ Some information NOT in appropriate sections
□ Many instances (>4) of misspellings, inappropriate abbreviations or terminology
□ No references listed or suboptimal references used. / □ Unprofessional tone/ language that would be considered inflammatory or derogatory

Grading for Team Based Care IPPE

Exemplary- 15 total points

Acceptable- 10-14 total points

Unacceptable- 0-9 total points- Revision will be requested