Soap note rubric

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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.

  1. The medical record should be complete and legible.

  2. The documentation of each patient encounter should include:

    1. The date

    2. The reason for the encounter

    3. Appropriate history and physical examination.

    4. Review of lab, xray data, and other ancillary services.

    5. Assessment

    6. Plan for care

  3. Past and present diagnoses should be accessible to the treating and/or consulting provider.

  4. The reasons for and results of xrays, lab tests, and other ancillary services should be documented or included in the medical record.

  5. Relevant health risk factors should be identified.

  6. The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented.

  7. The written plan for care should include, when appropriate:

    1. Treatment and medications, specifying frequency and dosage.

    2. Any referrals and consultations

    3. Patient/family education

    4. Specific instructions for follow up.

  8. The documentation should support the intensity of the patient’s evaluation and/or treatment, I ncluding thought processes and the complexity of medical decision-making.

  9. All entries to the medical record should be dated and authenticated.

  10. The CPT/ICD-9 codes reported on health insurance claim form or billing statement should reflect the documentation of the medical record.







History of present illness

Chief complaint only

1-3 elements identified

> 4 elements identified

4 elements + >3 chronic or inactive conditions identified.

Review of Systems


Items not pertinent to problem identified

Pertinent to problem 1 system with pertinent positives and negatives.

Pertinent to problem 2-9 systems, with pertinent positives and negatives

> 10 pertinent systems identified, with pertinent positives and negatives.

Past family and social history


Inappropriate items noted.

None appropriate to complaint

One appropriate to history itentified

>3 appropriate to history identified.


Physical Exam

Problem focused.

1-5 bullet points in system exam.

Inappropriate system examined.

Expanded problem focused 6-11 bullets

Detailed 12 bullets

Comprehensive exam. 9 body systems with 2 bullets in each system.

Decision Making

1 self limiting or minor problem

Multiple systems; interpretation of minor lab required

Multiple systems; review of >2 diagnostic studies required.

Multiple systems; complex patient; >2 diagnostic studies interpreted; >2 future studies planned.



0= long narrative, not specific diagnosis.

1=Self limited minor.

Established problem; stable or improved. Appropriate to history and assessment findings

New problem; no additional work up planned

New problem, additional work up planned.



Inappropriate therapy.

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.

** 0= failed to meet minimum requirement.

>22 = Exceptional; >21 points= A; >20 points = A-; >19 points = B+; >18 points = B

< 10 points= quality of documentation inadequate for accurate billing, litiginously risky, and fails to promote continuity of good care.

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