Psychiatric SOAP Note Rubric
Criteria
Ratings
Points
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
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