NU623 Unit 4 Assignment – SOAP Note Evaluation Rubric Criteria Ratings Pts

NU623 Unit 4 Assignment – SOAP Note Evaluation Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeICD-10 Code

2.5 pts

Highly Proficient

ICD-10 Code provided with appropriate modifiers congruent with the clinical information provided

1.5 pts

Marginally Proficient

ICD-10 Code provided with limited clinical information detail

0.5 pts

Not Proficient

ICD-10 code provided is not congruent with the clinical information provided

0 pts

Not evident

ICD-10 Code not provided

2.5 pts

This criterion is linked to a Learning OutcomeE&M CPT Code

2.5 pts

Highly Proficient

ICD-10 Code provided with appropriate modifiers congruent with the clinical information provided

1.5 pts

Marginally Proficient

ICD-10 Code provided with limited clinical information detail

1 pts

Not Proficient

ICD-10 code provided is not congruent with the clinical information provided

0 pts

Not evident

CPT Code not provided

2.5 pts

This criterion is linked to a Learning OutcomeSubjective Data

7.5 pts

Highly Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented and demonstrate consistent information across all aspects represented

6 pts

Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented and demonstrate consistent information across all aspects represented

4.5 pts

Marginally Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented but do not demonstrate consistent information across all aspects represented

3 pts

Approaching Proficiency

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are either not satisfactorily documented or do not demonstrate consistent information across all aspects represented

1.5 pts

Not Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented and do not demonstrate consistent information across all aspects represented

0 pts

Not evident

There are elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) that are not provided in the assignment

7.5 pts

This criterion is linked to a Learning OutcomeObjective Data

7.5 pts

Highly Proficient

Elements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS

6 pts

Proficient

Elements of objective data are appropriately documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS

4.5 pts

Marginally Proficient

Elements of objective data are satisfactorily documented but do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS

3 pts

Approaching Proficiency

Elements of objective data are either not satisfactorily documented or do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS

1.5 pts

Not Proficient

Elements of objective data are not satisfactorily documented and do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS

0 pts

Not evident

There are elements of objective data that are not provided in the assignment

7.5 pts

This criterion is linked to a Learning OutcomeAssessment

5 pts

Highly Proficient

Assessment designations and other elements in this section are adeptly documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data

4 pts

Proficient

Assessment designations and other elements in this section are appropriately documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data

3 pts

Marginally Proficient

Assessment designations and other elements in this section are satisfactorily documented but do not demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data

2 pts

Approaching Proficiency

Assessment designations and other elements in this section are either not satisfactorily documented or do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data

1 pts

Not Proficient

Assessment designations and other elements in this section are not satisfactorily documented and do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data

0 pts

Not evident

Assessment designations and other elements in this section are not provided in the assignment

5 pts

This criterion is linked to a Learning OutcomePlan

5 pts

Highly Proficient

Elements of the plan are adeptly documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented

4 pts

Proficient

Elements of the plan are appropriately documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented

3 pts

Marginally Proficient

Elements of the plan are satisfactorily documented but either do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented

2 pts

Approaching Proficiency

Elements of the plan are either not satisfactorily documented, or do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented

1 pts

Not Proficient

Elements of the plan are not satisfactorily documented, do not demonstrate application of current clinical practices for the identified assessment designations, and do not demonstrate congruence of information across all aspects represented

0 pts

Level 0

Elements of a plan are not provided in the assignment

5 pts

Total Points: 30

NU623 Unit 4 Assignment – SOAP Note Evaluation Rubric