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Category Exceptional 3 Satisfactory 2 Needs Improvement 1 Possibly Harmful 0 Score

Subjective Information is accurate and Accurate information Minor incorrect information and Major incorrect information and / or
complete and is organized and provided (as in / or information placed in the major omissions that make it unlikely
concise. The documentation is exceptional column), but incorrect location; omissions another provider would come to the
comprehensive to include all CC, could be more organized such as allergies, medications same A and P; major omissions such
HPI, PMH, SH, FH, Allergies, and succinct as HPI, ROS, PMH etc.
Meds, ROS etc.
Objective Accurate information is Accurate information is Incorrect information, or Incorrect information (major) or
organized and precise and does provided, but could be contains minor, but important omissions that make it unlikely
not include any major or minor more organized and information, or incorrect another provider would come to the
omission. succinct placement of information is same A and P (such as lab results)
Assessment Accurate information provided: Accurate information Incorrect information (minor) Incorrect information (major)
complete and concise provided but could be provided such as drug therapy included that could result in wrongly
description to include the more organized inconsistent with established identified drug therapy which may
diagnosis, supported logically by guidelines; contains problem not result in patient harm
subjective and objective data; discussed in S and O sections or
cites guidelines as appropriate information from P section

Plan Complete and appropriate in Appropriate information Missing or inconsistent Contains errors that could result in
every detail to include (same as exceptional information or using guidelines patient harm; fails to address correct
education, further investigation, column), but with minor that are not appropriate; major therapy; has missing or incorrect key
follow up, referral (if indicated) omissions omissions where another educational points (e.g. drug side
etc. practitioner is unlikely to come effects), follow up / referral)
up with the same plan
Overall Appropriate word choice and Few errors with word Incorrect or inappropriate word Incorrect or inappropriate word
grammar / terminology; no grammatical choice and terminology; choice or terminology (minor); choice or terminology (major); greater
medical errors; appropriate up to date fewer than 2 grammatical greater than 3 grammatical than 5 grammatical errors; few or no
terminology scientific references used, for errors; up to date and errors; some sources are sources are up to date, inappropriate
/ references instance textbooks, clinical appropriate sources used scientific / or up to date scientific references
practice guidelines
Total (from a possible 15)

Adapted from: Barnett, SG. Casey, G. Kopacek, KJ & Porter, AL. (2014). Evaluation of electronic SOAP note grading and feedback. Currents in Pharmacy
Teaching and Learning 6, 516-526.