Soap note rubric

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.
    

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