Exemplary Competent Developing Unmet

Subjective
Includes a direct quote
Includes a clear, concise Includes information but
from patient AND Information is
direct quote from patient information is NOT a
without other unrelated completely missing OR
Chief Complaint about presenting direct quote AND is not
information but is not inaccurate.
problem. clear NOR concise
clear OR concise.
3 2 1 0
Includes the presenting
problem and the 8
dimensions of the
May include the
problem (OLD CARTS/ Includes the presenting
presenting problem, may Information is
OLD CLASS). Connects to problem and 6-7
have </= 5 of dimensions completely missing OR
the CC and sets up the dimensions of the
of the problem (OLD completely
story for the problem (OLD CARTS/
History of Present Illness (HPI) CARTS/ OLD CLASS) disorganized/no clear
Assessment/Plan (this OLD CLASS). OR the
(OLD CARTS or OLD CLASS). AND/OR the connection connection. Clear
includes 3 tier diagnoses connection of the CC and
of the CC and the need for revisions and
pertinent information +/- the Assessment/Plan is
Assessment/Plan is remediations.
OR important disorganized.
disorganized.
components of OLD
CLASS that helps explain
your plan).
6 4 2 0
Includes (Major/Chronic,
Includes (Major/Chronic,
Trauma,
Trauma, Includes each medical
Hospitalizations), for Information is
Hospitalizations), for diagnosis but does not
each medical diagnosis, completely missing OR
each medical diagnosis, include year of diagnosis
Past Medical Hx either year of diagnosis clear need for revisions
year of diagnosis and or whether the diagnosis
OR whether the and remediations.
whether the diagnosis is is active or current
diagnosis is active or
active or current
current
3 2 1 0
 Exemplary Competent Developing Unmet
Includes a list of SOME of Includes a list of SOME of
Includes a list of all the
the patient’s reported. the patient’s reported.
patient’s reported.
medications AND/OR the medications AND/OR the
medications and the Information is completely
medical diagnosis for the medical diagnosis for the
medical diagnosis for the missing OR clear need for
Medications/ medication is missing medication is missing
medication (including revisions and
Allergies/ Immunization (includes SOME of the (includes FEW of the
name, dose, route, remediations.
following: name, dose, following: name, dose,
frequency, if taken as
route, frequency, if taken as route, frequency, if taken as
prescribed/last dose)
prescribed/last dose) prescribed/last dose)
3 2 1 0
Includes an assessment of
Includes an assessment of Includes an assessment of
at least 4 family members
at least 2-3 family members at less than 2 family
regarding, at a minimum,
regarding, at a minimum, members regarding, OR
genetic disorders, diabetes,
genetic disorders, diabetes, missing genetic disorders,
heart disease and cancer.
heart disease and cancer. diabetes, heart disease and
Includes all the following:
OR includes some of the cancer. OR includes few of Information is completely
tobacco use, drug use,
following: tobacco use, the following: tobacco use, missing OR clear need for
alcohol use, marital status,
Family Medical /Birth /Social Hx drug use, alcohol use, drug use, alcohol use, revisions and
employment status,
marital status, employment marital status, employment remediations.
current/previous
status, current/previous status, current/previous
occupation, sexual
occupation, sexual occupation, sexual
orientation, sexually active,
orientation, sexually active, orientation, sexually active,
contraceptive use, and
contraceptive use, and contraceptive use, and
living situation.
living situation. living situation

6 4 2 0
Includes 1-3 assessments Includes 1 assessments for
Includes a minimum of 3
for each body system each body system AND/OR
assessments for each body
AND/OR has most of the has some of the Information is completely
system and assesses
appropriate body systems appropriate body systems missing OR clear need for
appropriate body systems
ROS assessed related to the assessed related to the revisions and
directed to chief complaint
chief complaint AND/OR chief complaint AND/OR remediations.
AND uses the words
lacks the words “admits” lacks the words “admits”
“admits” and “denies”
and “denies” and “denies”
6 4 2 0
 Exemplary Competent Developing Unmet
Objective
Includes all 8 vital signs, (BP
(with patient position,
Includes ALL VS WITHOUT
auto/manual/location), HR,
parameters for the VS Information is completely
RR, temperature (with F or Includes some of the VS
OR missing OR clear need for
Vital Signs C & route), O2 Sat (on room AND lacks some of
lacks some of vital signs revisions and
air or O2 source), weight, parameters for the VS
WITH ALL the parameters remediations.
height, BMI (or percentiles
for the VS
for pediatric population)

4 3 2 0
Includes a minimum of 4
Includes a minimum of 2-4
assessments for each body Includes some assessments
assessments for each body
system and assesses at least for each body system AND Information is completely
system AND/OR assesses 5
5 body systems directed to lacks the appropriate body missing OR clear need for
Physical Exam or less body systems
chief complain. If ROS systems related to the chief revisions and
directed to chief complain.
assessed, then that system complain. AND/OR not all remediations.
AND/OR not all ROS
is assessed. ROS systems are assessed.
systems are assessed.

6 4 2 0

Assessment
Assessment statement Include 2-3 sentence Include a statement Include a statement Information is completely
statement summarizing the summarizing the pertinent summarizing the pertinent missing OR clear need for
pertinent findings from the findings from the history and findings from the history and revisions and remediations.
history and physical exam that physical exam that support physical exam that support
support primary diagnosis and primary diagnosis and should primary diagnosis and should
should include your include your impressions and include your impressions and
impressions and your your interpretation of all the your interpretation of all the
interpretation of all the above above information, AND/OR above information OR draws
information and draw from any draws from any clinical from any clinical professional
clinical professional knowledge professional knowledge or knowledge or DSM
or DSM criteria/therapeutic DSM criteria/therapeutic criteria/therapeutic models to
models to arrive at a diagnosis. models to arrive at a diagnosis. arrive at a diagnosis OR lacks
significant details in either
section.
 6 4 2 0

Exemplary Competent Developing Unmet

Includes some differential
Includes the 3 differential Includes the 3 differential
diagnoses as outlined on the
diagnoses as outlined on the diagnoses as outlined on the
SOAP template with minimum
SOAP template with pertinent SOAP template with some Information is completely
positive and negative rationale
positive and negative rationale positive and negative rationale missing OR clear need for
OR a statement of each. OR a
Differential Diagnoses AND clear statement of each. AND/OR a statement of each. revisions and remediations.
statement on the Clinical
OR a clear and concise Clinical OR a statement on the Clinical
Decision-Making Plan outlined
Decision-Making Plan outlined. Decision-Making Plan outlined.
BUT lacks details.
6 4 2 0
Plan
Includes appropriate
diagnostic/lab testing for the Includes some of the Includes minimal OR
Information is completely
CC and primary Dx OR appropriate diagnostic/lab inappropriate diagnostic/lab
missing OR clear need for
acknowledges “no diagnostic testing for the CC and primary testing for the CC and primary
Diagnostic/lab testing revisions and remediations.
testing clinically required at Dx Dx
this time”

6 4 2 0

Includes a detailed
Includes a pharmacologic
pharmacologic treatment plan
treatment plan for the primary
for the primary diagnosis
diagnosis (diagnoses) OR The
(diagnoses) OR states “NO
RX includes SOME of the
pharmacological measures
following: drug name, dose,
needed.” The RX includes ALL Includes a pharmacologic
route, frequency, duration,
the following: drug name, treatment plan BUT NOT all
and cost as well as education Information is completely
dose, route, frequency, the RXs AND/OR The RX is
related to pharmacologic missing OR clear need for
duration, and cost as well as missing key elements AND/OR
Pharmacological agent. If the diagnosis is a revisions and remediations..
education related to lacks the rationale behind the
chronic problem, student
pharmacologic agent. If the RX for this DX.
includes instructions on
diagnosis is a chronic problem,
currently prescribed
student includes instructions
medications as above. OR lacks
on currently prescribed
the rationale behind the RX for
medications as above with
this DX.
rationales.

6 4 2 0
 Exemplary Competent Developing Unmet
Includes a NON-
Includes a detailed NON-
pharmacologic treatment
pharmacologic treatment
plan for the primary
plan for the primary
diagnosis (diagnoses).
diagnosis (diagnoses).
The RX includes SOME of Includes a NON-
The RX includes ALL the
the following: name of pharmacologic treatment
following: name of
treatment, dose, route, plan for the primary
treatment, dose, route,
frequency, duration, and diagnosis (diagnoses).
frequency, duration, and
cost as well as education The non-pharmacologic Information is
cost as well as education
related to non- treatment is lacking key completely missing OR
related to non-
pharmacologic details. If the diagnosis is clear need for revisions
Non-Pharmacological pharmacologic
treatment. If the a chronic problem, and remediations.
treatment. If the
diagnosis is a chronic student includes minimal
diagnosis is a chronic
problem, student instructions on currently
problem, student
includes some of the prescribed treatments
includes instructions on
instructions on currently OR lacks the rationale.
currently prescribed
prescribed treatments as
treatments as above.
above AND/OR gives the
AND gives the rationale
rationale behind the RX
behind the RX for this DX.
for this DX.
6 4 2 0
Includes limited
Includes at least 3 Includes some strategies
strategies to promote
strategies to promote to promote and develop
and develop skills for
and develop skills for skills for managing their Information is
managing their illness
managing their illness as illness as well as self- completely missing OR
AND/OR lacks self-
well as self-management management methods clear need for revisions
Patient Education management methods
methods on how to on how to incorporate and remediations.
on how to incorporate
incorporate healthy healthy behaviors into
healthy behaviors into
behaviors into their lives. their lives.
their lives.
6 4 2 0

Exemplary Competent Developing Unmet

 Includes ALL aspects of this
section or discusses why
Includes SOME aspects of
they are not needed clearly.
this section. The directions
The directions are clear and
are NOT objective and
concise (objective and Includes minimal aspects of Information is completely
Referral/Consultations/ measurable. These
measurable components) to this section. The directions missing OR clear need for
Anticipatory Guidance components are somewhat
the patient and for any are NOT clear OR lacks revisions and
appropriate and have some
other providers to rationales. remediations.
rationales.
understand. These
components are
appropriate and have
rationales.
3 2 1 0
Includes clear and easy to
Includes a recommendation
follow recommendation for Includes a recommendation
for follow up OR there are
follow up, including time for follow up AND there are
instructions for the patient
frame (i.e. x # of instructions for the patient Information is completely
to follow when things are
days/weeks/months) AND to follow when things are missing OR clear need for
not improving, worsening,
Follow-up: there are clear instructions not improving, worsening, revisions and
or life-threatening AND/OR
for the patient to follow or life-threatening BUT remediations.
lacks important details
when things are not lacks details OR are in
AND/OR difficult to follow
improving, worsening, or medical terms, etc.
directions.
life-threatening.
6 4 2 0
Includes pertinent findings
in the social history as well Includes some pertinent
Forgot to include pertinent
as specific plan of care findings in the social history Information is completely
findings in the social history
needs in the Plan section of OR some of the plan. Has 1- missing OR clear need for
AND without specific plans
SDOH the SOAP note. Has 1-3 3 SDOH needs without revisions and
OR very difficult to follow
SDOH needs with specific, specific objective, easy to remediations.
plans for the patient.
objective, easy to follow follow plans for the patient.
plans for the patient.
6 4 2 0

` Exemplary Competent Developing Unmet

 Overall
Identifies 1-2 areas for self- Identifies no area for self- Information is completely
Identifies 1-2 areas for self-
study related to your SOAP study related to your SOAP missing OR clear need for
study related to your SOAP
Progress Reflection note WITHOUT describing note OR lacks any revisions and
note and describes plan.
plan. description of a plan. remediations.
6 4 2 0

Identifies 2-3 resources for

any part of the SOAP but There are no APA
specifically in the A and P. Has at least one resource Has at least one resource resources given OR it is
Uses proper APA technique BUT there are some BUT there are multiple clear there is a need for
per the most update APA mistakes in the APA mistakes in the APA revisions and
APA citation/ References manual in both in-text technique in either in-text technique in either in-text remediations related to
citations and references. citations and references. citations and references. APA citation style
Scholarly/student paper throughout.
outlines are not needed
(such as title page, etc.)

3 2 1 0

Uses some scholarly Information is completely

Uses proper, scholarly Uses mostly scholarly
grammar AND/OR has missing OR clear need for
grammar, lacks obvious grammar AND/OR has
multiple professional revisions and
Grammar professional errors. minimal professional errors.
errors. remediations.
3 2 1 0