SOAP NOTE RUBRIC Principles of documentation: The official principles below have been developed jointly by representatives of the American Hospital Information Management Association, the American Hospital Association, the American Managed Care and Review Association, Blue Cross and Blue Shield Association and the Health Insurance Association of America.
The medical record should be complete and legible.
The documentation of each patient encounter should include:
The reason for the encounter
Appropriate history and physical examination.
Review of lab, xray data, and other ancillary services.
Plan for care
Past and present diagnoses should be accessible to the treating and/or consulting provider.
The reasons for and results of xrays, lab tests, and other ancillary services should be documented or included in the medical record.
Relevant health risk factors should be identified.
The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented.
The written plan for care should include, when appropriate:
Treatment and medications, specifying frequency and dosage.
Established problem; stable or improved. Appropriate to history and assessment findings
New problem; no additional work up planned
New problem, additional work up planned.
Appropriate pharmacological (dose& frequency) and nonpharmacological therapies
Appropriate documentation of futher diagnostic studies; pharmacologic and non pharmacologic; anticipatory guidance regarding health promotion and disease prevention; appropriately notes instructions for RTC/Follow up
Also includes appropriate referral consultation of complex patient.