Evaluation criteria: You are evaluated on each of the four core aspects of a SOAP note (subjective, objective, assessment, and plan) as well as the overall effectiveness of the note.
Subjective:
Information reported appropriately focused and pertinent.
Contains pertinent and extraneous information.
Omits key pertinent information.
Objective:
Information reported appropriately focused and pertinent.
Contains pertinent and extraneous information.
Omits key pertinent information.
Assessment:
Working diagnosis is clear and presented concisely; important differential diagnoses are addressed (i.e. alternate diagnoses being seriously considered, evaluated, or empirically treated).
Presenting symptom or abnormal finding substituted for working diagnosis (don’t do this no matter what house staff say) but major problem is clear and differential diagnoses are discussed when appropriate.
Working diagnosis or major problem is unclear and/ or no clear prioritization of problems.
Major problem or diagnosis is not addressed.
Plan:
The plan is clearly stated along with a clear rationale.
There is an attempt at a plan but it is unclear that the rationale is understood.
Critical aspect of the plan is missing or it is clear the student does not understand the rationale for the plan.
Overall Effectiveness
Overall Effectiveness - Length:
Balances conciseness with appropriate detail
Needs to work on conciseness but discussion is basically good, just long
Too long because of too much extraneous detail and/or poor organization of thoughts
