PSYCH SOAP 1
Grading Rubric for SOAP Notes Updated Course: NSG-535-IKK - Adv Prac in Psych/MH Nurs I
Criteria Unacceptable 0 points
Acceptable 8 points
Good 14 points
Excellent 20 points
Criterion Score
Subjective Data / 20CC is not recorded.
HPI does not reflect
a chronological ac-
count of symptoms
that are sufficiently
descriptive to vali-
date Dx per DSM-5
criteria. Pertinent
negatives are not in-
cluded. The longitu-
dinal course of ill-
ness is nonexistent.
CC is clear. HPI pro-
vides an account of
symptoms that are
descriptive,
nonchronological,
without context,
and do not clearly
validate Dx per
DSM-5 criteria. Few
pertinent negatives
are included. A lon-
gitudinal course of
illness is unclear.
Current medications
are included.
CC is clear, concise
and verbatim from
pt. HPI is thorough
yet concise and pro-
vides a chronologi-
cal account of symp-
toms with some
contextual factors
that are sufficiently
descriptive (oldcarts)
to validate Dx per
DSM-5 criteria.
Pertinent negatives
are included. A lon-
gitudinal course of
illness is apprecia-
ble. Current psychi-
atric medications
and response are
included.
CC is clear, concise
and verbatim from
pt. HPI is thorough
yet concise and pro-
vides a chronologi-
cal account of symp-
toms and contextual
factors that are suf-
ficiently descriptive
(oldcarts) to validate
Dx per DSM-5 crite-
ria. All pertinent
negatives are in-
cluded. A longitudi-
nal course of illness
is clear. Current psy-
chiatric medications
and response are
included.
9/2/26, 6:42 PM Soap Note 1 (assignment folder) - NSG-535-IKK - Adv Prac in Psych/MH Nurs I - L.I.V.E. - Wilkes University
https://live.wilkes.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=709130&grpid=0&isprv=0&bp=0&ou=387997 1/6