Suffolk

County Community College

School of Nursing

NUR123 SOAP NOTE SCORING RUBRIC FORM

Student: ____________________________________________ Date: _________________________

Item of SOAP

Value

Scored

Comments

States pt. problem as appropriate:

Reason for Seeking Care (CC)
Present Health or HPI
Past health
Allergies and Reactions (foods and
medications)
Current Medications including OTC & herbal
meds
Pertinent negative data
Pertinent positive data
Possible Points 20
Documents PE findings as appropriate:
Inspection
Includes Normal and Abnormal findings
Palpation
Includes Normal and Abnormal findings
Percussion
Includes Normal and Abnormal findings
Auscultation
Includes Normal and Abnormal findings
Vital Signs as appropriate
Possible Points 50
States Nursing Diagnosis in PES format
Possible Points 10
Lists Nursing Interventions with focus on
Health teaching
Health promotion
Possible Points 20

TOTAL Possible Points 100

A

P

Passing grade 70 % or more

Assessment of allergies and medications MUST be included in every system.

NUR123/PAK/December 2014