SOAP Note Quality Research Study

Note Evaluation

Note Evaluation

Clinical SOAP Note

Read the note carefully, then complete the evaluation on the right.

Chief Complaint

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Subjective

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Objective

Medications:

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Mental Status Exam:

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Labs:

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Assessment

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Diagnoses:

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Plan

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Part 1: Quality Evaluation

Rate this note on each attribute (1=Poor to 5=Excellent)

Attribute 1
Not at all
2 3 4 5
Extremely
How accurate is the note?
The note is true. It is free of incorrect information.
How thorough is the note?
The note is complete and documents all issues of importance to the patient.
How useful is the note?
The note is relevant, providing valuable information and/or analysis.
How organized is the note?
The note is well-formed and structured in a way that helps the reader understand the patient's clinical course.
How comprehensible is the note?
The note is clear, without ambiguity or sections that are difficult to understand.
How succinct is the note?
The note is brief, to the point, and without redundancy.
How synthesized is the note?
The note reflects understanding of the patient's status and ability to develop a plan of care.
How internally consistent is the note?
No part of the note ignores or contradicts any other part.
How free from hallucination is the note?
The note only contains information verifiable by the session.
How free from bias is the note?
The note is free of bias and contains only objective information.