Course Syllabus
Course Number: OTHA 2261
Course Name: Clinical II (Adults)
Revised: 8-2015
Hours: Varies depending on site
Semester Credit Hours: 2
Lecture Hours per week: 0
Lab Hours per week: 8
Contact Hours per Semester: 128
Prerequisites: OTHA 1405, OTHA 1409, OTHA 1315, OTHA 1341, OTHA 2260
Co-Requisite: OTHA 1349, OTHA 2301, OTHA 1419
Instructor: Nicki Greenhouse, BS, COTA
Instructor’s Office Location and Phone Number: HNS 2208; 903-694-4022 or 903-649-1035
E-mail Address: ngreenhouse@panola.edu
Course Description: The Clinical II (Adult) course is a health-related work-based learning experience that
enables the student to apply specialized occupational therapy theory, skills, and concepts. Direct supervision is
provided by the clinical professional. (Workforce Education Manual, 2012-2013)
Purpose and Goals of the Course: As outlined in the learning plan, the student will apply the theory,
concepts, and skills involving specialized materials, tools, equipment, procedures, regulations, laws, and
interactions within and among political, economic, environmental, social and legal systems associated with the
delivery of OT services at the clinical site; demonstrate legal and ethical behavior, safety practices,
interpersonal and teamwork skills, and appropriate written and verbal communication skills using industry
terminology.
Course’s Relationship to Curriculum:
This course provides students with opportunities to synthesize and integrate didactic information primarily from
OTHA 1349, but also reinforces content learned in both OTHA 1419 and 2301. Through direct, supervised
client contact, students are able to learn first-hand how various conditions affect the person and their preferred
or required occupational roles. Students apply learned interviewing skills and techniques to explore how the
client’s environment(s) supports or hinders occupational performance. Through case studies, students must
demonstrate clinical reasoning skills as they are challenged to provide rationales for intervention choices.
Service documentation is practiced collaboratively through video and face-to-face client intervention.
Assignments
Level I Student Evaluation Form
Online Case Study Assignments
Level I FW Assignments
Clinical Reasoning Exam (CRAK)
Weight
60%
20%
10%
10%
Grading Scale
% Score
Letter Grade
90-100
A
80-89
B
75-79
C
60-74
D
Below 60
F
Note 1: No scores will be rounded.
Note 2: All rules and regulations printed in the College catalog, The Pathfinder and the OTA Student Policy
Manual will be reinforced throughout this course.
Note 3: The OTA Program will not tolerate any form of academic dishonesty as defined in The Pathfinder or
unethical behaviors as defined in the OTA Program’s Student Policy Manual. Any student participating in
academic dishonesty or unethical behaviors of any type will receive a zero (0) on the assignment or exam and
may be subject to further disciplinary action.
Student Responsibilities
1.
Students are expected to show respect for fellow classmates and instructors by being punctual for all
class periods.
2.
Students should complete all reading assignments and or lab assignments prior to class.
3.
Students are expected to participate actively in class discussions and experiences.
4.
It is the student’s responsibility to consistently monitor the class process through the use of the online
learning management system. Students are expected to print out all course materials prior to the class
date listed on the learning management system. Given this expectation, the student should maintain
access to a reliable computer system to remain in good standing in the course.
5.
6.
7.
8.
9.
10.
11.
12.
Students should notify the instructor in advance if unable to take a scheduled examination. If not,
unexcused absence will result and the student will receive a zero for the exam. A make up test will not be
given in this circumstance.
Students are responsible for all materials missed due to absences.
Grades or points allotted for daily work, quizzes, and labs cannot be made up in the case of an absence.
Students are expected to turn in completed assignments on time. The course instructor may extend the
deadline if notified of extenuating circumstances prior to the due date. Students can expect a 20 point
deduction for every day it is late.
Grades or points allotted for daily work, quizzes, and labs cannot be made up in the case of an absence.
Students are expected to accept constructive feedback and modify behavior as appropriate.
When interacting with peers, College staff and faculty, students are expected to be positive, sensitive,
considerate, polite and tolerant.
For specific conduct and behavior expectations, refer to the OTA Program Student Policy Manual.
Attendance:
Any student who does not come to class (all or in part) and does not call Mickie Cash, OTA department
secretary in advance will lose 5 points from his/her overall COURSE grade per occurrence. For example, if
you have a 93% average at the end of the semester and you failed to report one absence or arrived at class
late without reporting, your average will be adjusted to an 88% which would cause you to earn a “B” for the
course. If Mickie does not answer, please leave a message as a last resort. It’s simple common courtesy—
call if you are going to be late or absent. When a student arrives late or leaves early, for any reason, it is
considered a tardy. Three tardies equates to one absence. Because of the experiential nature of OTA
education, attendance is required to master the course objectives. If a student is absent for more than 11% of
the course hours, the instructor may withdraw the student from the course.
If any student in this class has special classroom or testing needs because of a physical, learning, or emotional
condition, please contact ADA Counselor in the Administration Building, telephone 903-693-1123 to make
arrangements for any required accommodations within the first seven days of the semester. Withdrawing from
a course is the student’s responsibility. If you do not withdraw yourself, you will receive an F on your transcript
for this course.
After studying the material presented in the texts, lecture, laboratory, Canvas assignments, and other
resources, the student should be able to complete all learning objectives listed below with a minimum
competency of 75%.
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 2
LEARNING OBJECTIVES:
After completion of materials presented in this course, the student will be able to:
1. Use sound judgment in regard to safety of self and others and adhere to safety regulations throughout
the occupational therapy process as appropriate to the setting and scope of practice. B.2.8
2. Gather and share data for the purpose of evaluating client(s)’ occupational performance in activities of daily
living (ADLs), instrumental activities of daily living (IADLs), education, work, play, rest, sleep, leisure, and
social participation. Evaluation of occupational performance includes

The occupational profile, including participation in activities that are meaningful and necessary
for the client to carry out roles in home, work, and community environments.

Client factors, including values, beliefs, spirituality, body functions (e.g., neuromuscular,
sensory and pain, visual, perceptual, cognitive, mental) and body structures (e.g.,
cardiovascular, digestive, nervous, genitourinary, integumentary systems).

Performance patterns (e.g., habits, routines, rituals, roles).

Context (e.g., cultural, personal, temporal, virtual) and environment (e.g., physical, social).

Performance skills, including motor and praxis skills, sensory-perceptual skills, emotional
regulation skills, cognitive skills, and communication and social skills. B.4.4
3. Document occupational therapy services to ensure accountability of service provision and to meet
standards for reimbursement of services, adhering to the requirements of applicable facility, local, state,
federal, and reimbursement agencies. Documentation must effectively communicate the need and
rationale for occupational therapy services. B.4.10
4. Use the teaching-learning process with the client, family, significant others, colleagues, other health
providers, and the public. Collaborate with the occupational therapist and learner to identify appropriate
educational methods. B.5.19
5. Effectively interact through written, oral, and nonverbal communication with the client, family, significant
others, colleagues, other health providers, and the public in a professionally acceptable manner.
B.5.20
6. Grade and adapt the environment, tools, materials, occupations, and interventions to reflect the
changing needs of the client and the sociocultural context. B.5.23
7. Recognize and communicate the need to refer to specialists (both internal and external to the profession)
for consultation and intervention. B.5.22
8. Monitor and reassess, in collaboration with the client, caregiver, family, and significant others, the effect
of occupational therapy intervention and the need for continued or modified intervention, and
communicate the identified needs to the occupational therapist. B.5.28
9. Facilitate discharge planning by reviewing the needs of the client, caregiver, family, and significant
others; available resources; and discharge environment, and identify those needs to the occupational
therapist, client, and others involved in discharge planning. This process includes, but is not limited to,
identification of community, human, and fiscal resources; recommendations for environmental
adaptations; and home programming. B.5.29
10. Recommend to the occupational therapist the need for termination of occupational therapy services
when stated outcomes have been achieved or it has been determined that they cannot be achieved.
Assist with developing a summary of occupational therapy outcomes, recommendations, and referrals.
B.5.31
11. Document occupational therapy services to ensure accountability of service provision and to meet
standards for reimbursement of services. Documentation must effectively communicate the need and
rationale for occupational therapy services and must be appropriate to the context in which the service
is delivered. B.5.32
12. Identify the potential impact of current policy issues and the social, economic, political, geographic, or
demographic factors on the practice of occupational therapy. B.6.2
13. Under the direction of an administrator, manager, or occupational therapist, collect, organize, and
report on data for evaluation of client outcomes. B.5.30
14. Effectively communicate and work interprofessionally with those who provide services to individuals
and groups in order to clarify each member's responsibility in executing an intervention plan. B.5.21
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 3
15. Implement intervention strategies to remediate and/or compensate for cognitive deficits that affect
occupational performance. B.5.8
16. Describe the role of the occupational therapy assistant in care coordination, case management, and
transition services in traditional and emerging practice environments. B.5.27
Performance/
Learning Outcome
1-5,10,12,13,14,15,
17
6,7,8,9,11,16
6,7,8,9,11
Method of Measurement
The student will achieve at least an 80% on the Level I Fieldwork
Assignments.
The student will achieve at least an 80% on each Online Case Study
Assignments.
The student will achieve at least a 90% on the Clinical Reasoning and
Assessment of Knowledge (CRAK) Exams.
SCANS
Basic Skill Competencies
A. i, ii, iv, v
B. i, ii, iii, iv, v
C. i, ii, iii, iv, v
SCANS
Workplace Competencies
A. i, iii, iv
B. i, ii, iii
C. i, ii, iii, iv
D. i
Texts, Materials, and Supplies: None required.
Evaluation/Assignment Descriptions:
Level I Student Evaluation Form - 60% (minimum of 72 hours)
 Onsite FW Time – (72-96 hours)
You are assigned to a clinical site that specializes in occupational therapy services for adults with a variety of
physical disabilities. They range from home health settings, skilled nursing facilities, inpatient and outpatient
rehabilitation centers. You will be attending this site at least six to eight (6-8) hours one time weekly for twelve
(12) weeks. During this time, you will observe and assist where possible in direct patient treatments and attend
meetings and clinic management. See the Clinical Manual for more details as well as the list of FW site
assignments which can be found under the “General Information” Module. Your FWE will complete a Level I
Fieldwork – Clinical II – Adults Student Evaluation Form. You will provide the FWE an evaluation as
well at the end of the rotation. (See attached grading forms)
Level I FW Assignments – 10% (minimum of 22 hours)
 Treviso Transitional Care Center Clinical Site Visit - (6-8 hours)
Karen Rich, OTR, is the Program Director for a large inpatient rehabilitation center in Longview, TX. She has a
strong occupation based practice and truly embraces what she “preaches”. You will learn so much during your
time there with her. You will need to sign up for one of the days available.
 SOAP Notes – (2 hours)
You will submit at least two (2) SOAP notes that will be graded. One will be over a given scenario with class
discussion and the other will be over a session you observed while with Karen Rich, OTR, at Treviso
Transitional Care Center. (See grading rubric)
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 4
 Individual Case Study – (14 hours)
You will select one patient at your rotation to complete this case study. This will be a one page narrative
reflection paper which will include the following information. (See Grading Rubric)
1) Who is the client (person, including family, caregivers, and significant others; population; or organization)?
2) Why is the client seeking services, and what are the client’s current concerns relative to engaging in
occupations and in daily life activities? What premorbid conditions are affecting the occupational
performance?
3) What areas of occupation are successful, and what areas are causing problems or risks?
4) What contexts and environments support or inhibit participation and engagement in desired occupations?
(Consider current setting and d/c options.)
5) What is the client’s occupational history (i.e., psychosocial status, life experiences, values, interests,
previous occupational patterns of engagement in daily life activities, the meanings associated with them)?
6) What are the client’s priorities and desired outcomes?
7) How do healthcare payer source(s) effect OT service provision and planning?
8) Discuss how FWE uses the teaching-learning process with client, family or other professionals.
 Clinical Logs (See attached form and rubric)
You will complete two clinical logs for this rotation. List Onsite FW, Treviso Transitional Care Center Clinical
Site Visit, SOAP notes and Individual Case Study hours on one labeled “FW Assignments”. The second log
titled “Online Assignments” will have the Online Case Study Assignments and CRAK Exam hours listed. This
is an official document and all the rules regarding documentation apply. Logs must be neat and error free.
They should be completed in black ink only. If an error occurs, it should have one line and initialed. You
should accurately total each log. See attached rubric for scoring guidelines.
Online Case Study Assignments – 20% (15 hours)
Students will complete five (5) online learning assignments that are based on scenarios of real patient stories.
Diagnostic categories represented in this assignment include: Neurologic, Orthopedic, Pulmonary/Cardiac and
Cognitive Disabilities. Each case scenario will have questions, research tasks and short essay discussion
postings to facilitate comprehension and application of service provision. More information will be provided on
module content pages.
Clinical Reasoning and Assessment of Knowledge (CRAK) – 10% (12 hours)
Students will take 4 practice Certification Exam tests throughout the semester consisting of approximately
20 questions each, with 3 attempts to pass each test. Students must earn at least a 90% on each exam in
order to receive a grade for exam as well as clinical hours. Students will earn 3 clinical hours for each
exam passed with a 90% for a possible total of 12 clinical hours.
Students MUST have a total of 128 combined fieldwork hours by the end of the semester to complete
the requirements of Clinical II from above assignments.
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 5
Student Name:
Fieldwork Educator’s Name:
Facility Name:
OTHA 2261
Level I Fieldwork – Clinical II – Adults
Student Evaluation Form
The fieldwork educator should keep each of the following areas in mind as the student completes his/her
fieldwork rotation. Please complete this form and discuss your grading with the student on their last day of
fieldwork. Keep a copy for your records and give the original to the student to submit to the course
instructor. Please justify your numerical scores as your comments are vital to the student’s growth. Circle the
number of the appropriate performance score for each area per the following scale. Partial points may be
given where appropriate. Total all points to determine the student’s final numerical and letter grade. A 75 total
(75%) is the cutoff score for passing this aspect of the course.
1 ------ 7.5 passing ------ 10.
(Average)
1. PROFESSIONALISM
a. Commitment to Learning: The ability to self assess, self correct and self direct; identify needs
and sources of learning; continually seek new knowledge and understanding. Examples- asks
appropriate questions, is consistently engaged, actively observing and is enthusiastic about
learning.
1
2
3
4
5
6
7
8
9
10
b. Professional Behavior: The ability to exhibit appropriate professional conduct and to
represent the profession effectively. Examples- handles personal problems/stress without it
interfering with fieldwork duties, expresses empathy to client situations, arrives to fieldwork at
specified time, responds appropriately to constructive feedback.
1
2
3
4
5
6
7
8
9
10
c. Professional Appearance: The ability to demonstrate appropriate professionalism in dress,
hygiene, grooming, and alertness. Examples- adheres to facility dress code, keeps hair and
nails neat where they don’t interfere with tx, is “in the moment with the client”- gives full attention
to situation at hand.
1
2
3
4
5
6
7
8
9
10
COMMENTS:
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 6
2. EFFECTIVE RELATIONSHIPS
a. Interpersonal Skills: The ability to communicate effectively with patients, families, colleagues,
other health care professionals and the community; deals effectively with cultural/ethnic diversity
issues. Examples-Shows respect for others, easily and readily establishes rapport, works
effectively with others.
1
2
3
4
5
6
7
8
9
10
b. Use of Constructive Feedback: The ability to identify sources, seeks out and effectively asks
for feedback to improve performance. Examples- actively listens asking for clarification and
then modifies behaviors as requested.
1
2
3
4
5
6
7
8
9
10
COMMENTS:
3.
COMMUNITY SERVICE
a. Responsibility: The ability to fulfill commitments and be accountable for actions and outcomes.
Examples- consistently carries out given tasks without redirection, timely completion of
assignments or group activities, takes responsibility and apologizes for mistakes and then takes
steps to remedy or correct the situation.
1 2 3 4 5 6 7 8 9 10
b. Effective Use of Time and Resources: The ability to obtain the maximum benefit from
available resources. Examples-completes task within given time frame, takes initiative to
remain productive throughout the day, mindful to not waste resources.
1 2 3 4 5 6 7 8 9
COMMENTS:
10
4. REASONING SKILLS
a. Evaluation/Screening: In collaboration with and under direct supervision of facility staff, the
student will accurately complete an interview to gather relevant data about the client that
supports the intervention process. Examples- able to obtain basic information from files,
demonstrates ability to collaborate with other disciplines to understand client’s “story” and
needs, completes screening tools using professional terminology.
1 2 3 4 5 6 7 8 9 10
b. Intervention: In collaboration and under the direct supervision of facility staff, the student will
select, provide and adapt therapeutic activities that enhance occupational performance.
Examples - seems prepared and able to facilitate group or individual session, adapts session
process as needed, ends session in a timely basis, able to adjust subsequent interventions as
needed.
1
OTHA 2261 – Clinical II (Adults) – Revised 8/15
2
3
4
5
6
7
8
9
10
Page 7
c. Safety Awareness: The ability to recognize and respond to the safety needs of clients, self,
and other disciplines working in the setting. Examples- notices potential hazards in group or ax
facilitation, keeps track of and safely handles media supplies, monitors w/c and other equipment
for problems, is aware of environment and removes all items that may lead to a potential fall or
other injury.
1 2 3 4 5 6 7 8 9 10
COMMENTS:
STUDENT PERFORMANCE OVERALL FEEDBACK
Areas of Strength:
Areas of Growth:
SCORE: ________/100%
Fieldwork Educator’s Signature
Date
Student’s Signature
Date
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 8
Panola College OTA Program
Student Evaluation of Fieldwork Instruction
Student Name: ______________________________Course: __________________
Facility Name: __________________________________________
This evaluation tool should be completed (typed) by the student and discussed with the fieldwork educator
(FWE) by the last week of the fieldwork rotation. A copy should be left with the FWE and the original returned
to the course instructor by the published due date.
Complete the questions below thoughtfully and accurately.
Provide constructive feedback with examples for your score in each area.
1. Clinical Site
The clinical site provides a student-friendly environment that supports the learning process.
1
Strongly Disagree
Comments:
2
Disagree
3
Agree
4
Strongly Agree
2. Professionalism
The fieldwork educator (FWE) demonstrates professional behaviors consistent with those instilled by the
Panola College OTA program. (i.e. initiation, dependability, respectfulness, organization, communication skills,
cooperation, and adherence to safety requirements)
1
Strongly Disagree
2
Disagree
3
Agree
4
Strongly Agree
Comments:
3. Therapeutic Use of Self
The fieldwork educator cultivates a therapeutic relationship (planned use of personality as a part of the
intervention process) and demonstrates the ability to connect interpersonally with their clients.
1
2
3
4
Strongly Disagree
Agree
Strongly Agree
Disagree
Comments:
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 9
4. Clinical Reasoning
The fieldwork educator demonstrates and discusses clinical reasoning for selection of evidence based
treatment intervention types. (FWE explains why the intervention is the best choice)
1
Strongly Disagree
2
Disagree
3
Agree
4
Strongly Agree
Comments:
5. Practice Skills
The fieldwork educator demonstrates the ability to implement effective occupation based, client centered
interventions (meaningful to client and goal directed).
1
Strongly Disagree
2
Disagree
3
Agree
4
Strongly Agree
Comments:
6. Suggestions
A. The best part about being at this facility was….
B. Something you might think about adding to this experience is…..
We have mutually shared and clarified the information above.
Date: ____________________
Fieldwork Educator:
__________________________ ________________________
(printed name)
(signature)
Student:
__________________________ _________________________
(printed name)
(signature)
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 10
GRAND TOTAL OF HOURS IN FIELDWORK: ________
Panola College OTA Program
Level I Fieldwork – Clinical II - Adults
Clinical Log – FW Assignments
(To be completed by the student)
Student Name: _______________________Facility: _________________________________
Fieldwork Educator: _______________________________
Date
In
Out
In
Out
Daily Time
1-06-08
7:55
12:00
12:45
4:23
7 hrs 43 min
FWE Signature
Total Time
For Office Use Only:
Verified:
Time
Log must be neatly completed in black ink. This is an official document.
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 11
Panola College OTA Program
Level I Fieldwork – Clinical II - Adults
Clinical Log – Online Assignments
(To be completed by the student)
Student Name: _______________________Facility: _________________________________
Fieldwork Educator: _______________________________
Date
In
Out
In
Out
Daily Time
1-06-08
7:55
12:00
12:45
4:23
7 hrs 43 min
FWE Signature
Total Time
For Office Use Only:
Verified:
Time
Log must be neatly completed in black ink. This is an official document.
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 12
OTHA 2261
Clinical II – Adults
Clinical Log
Grading Rubric
Student: ___________________________________________
Description
of
Criterion
Presentation
 Neat and legible

Neat and legible
in all areas;
black ink only
Legible in some
areas; black ink
only
Not legible in
most areas
AND/OR black
ink not used
Error free
One error; error
documented
with one line
and initialed
2 or more
errors; AND/OR
error(s) not
documented
correctly
One log
subtotaled
correctly; grand
total provided
Both logs not
subtotaled
correctly
AND/OR grand
total not
provided
If error occurs, documented
with one line and initialed
Each log
with subtotaled
correctly; grand
total provided
Grand total provided in and totaled
designated area with correct correctly
number of hours
Hours Totaled Correctly
 Each log subtotaled
correct number of hours

3 pts.
Black ink only
Rules of Documentation
 Error-free

5 pts.
0 pts.
Total Points _____/15
Comments:
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 13
OTHA 2261
Clinical II – Adults
Student Evaluation of Fieldwork Instruction
Grading Rubric
Student: ___________________________________________
Description
of
Criterion
Ratings
Points
Typed, relevant quality
feedback provided for each
category
Full Marks
50 pts.
No Marks
0 pts.
50 pts.
Typed, thoughtful relevant
suggestions provided in BOTH
sections
Full Marks
10 pts.
No Marks
0 pts.
10 pts.
Total Points _____/60
Comments:
A checklist for quality feedback:
1. Are specific behaviors described (vs. non-specific) – Even my FWE’s team member, Carol
(the PTA) spent time helping me learn about some mobility devices. VS The site was really
friendly.
2. Are the behaviors described clearly? – The way you were able to maintain respectfulness
and remain calm even when the entire Davis family was angry and upset is a mark of true
professionalism. I learned so much about connecting and communicating with patients and
family just by watching you! VS My FWE was highly professional in every way!
3. Are content and tone constructive and helpful (vs petty, mean, antagonistic)? – You can
get difficult patients to cooperate just by the way that you joke and tease with them. I wish I
could see more of that lighter side of you when it is just the two of us. VS You seem two-faced
in that you are all happy and joking when we are with the patients but as soon as it is just the
two of us, you seemed to swell up like a toad.
4. Is the feedback descriptive (vs evaluative)? – I feel that I could have benefitted more if you
would have given your opinion about my tx session during the session as opposed to
afterwards. VS You set me up to fail by not giving me feedback during my tx sessions.
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 14
Grading
Criteria
OTHA 2261 – Clinical II – Adults – Individual Case Study Grading Rubric
2
3
4
Needs Improvement:
Meets Standards:
Exceptional:
has some qualities, but has
shows good level of skill,
shows high level of
several areas that need more
innovation and critical
skill, innovation and
info or errors in critical thinking
thinking
critical thinking
Reflective Paper
 Professional Presentation
 Content
Data Gathering Process
 Initiative, Time and Effort
 Sources used for data
collection
 Thoroughness of data
collection
 Inclusion of pertinent
information needed
Analysis of Interview Data
 Assessments of data and
its impact on functional
outcome
Intervention
 Plans, selects, implements
(adapts/grades/etc.)
 Intervention review and
discharge planning
considerations
Self-Evaluation
 What was learned through
the process?
 What worked with the
process, what would you
do differently?
Total Score _______/ 16
Comments:
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 15
1
Unsatisfactory:
several areas need attention;
lacks depth in critical
thinking and application
Reader’s ability to
follow and utilize the
information. Content
accuracy.
1
Reader cannot follow
info to gain a clear
picture of client.
Sentences about a
given ax are not placed
together. Little to no
specific data provided.
SOAP Note Grading Rubric
2
3
Reader can gain some
Reader has some
insight into the client’s
difficulty in following
needs and skill levels. May
student thoughts and
have some data not fully
sequence of events.
addressed in sections. Be
Need to address client
sure to address given goal
skill level further and
areas fully.
address goal areas in
more detail.
4
Information is easily understandable
and effectively communicates the
need and rationale for OT services.
All info is addressed in correct
sections and vice-versa. All sections
are present and appropriate.
Correct placement of
data into specific
sections. Correct
organization.
Note reflects student’s
lack of understanding
for section content or
requirements, some or
more sections were not
addressed
Student able to give
basic details but needs to
review the format again,
several errors made on
placement of info.
Some errors with section
placement, note has fair
amount of data presented
in each section to reinforce
other sections, slight
review of format is needed
All sections are present and have
pertinent data presented. All
sections reflect or further explain
data in other sections. Adequate
amount of info in all areas. Good
overall flow of data.
Grammar and/or
spelling issues.
Error Corrections
Work has 4 or more
spelling/ grammatical
issues. Errors are
scribbled out or not
addressed at all. No
sentence structure.
Work has 2 spelling or
grammatical issues.
Errors are not fully
addressed per
requirements given in
class. Sentence structure
needs improving.
Work has 1 spelling or
grammatical issue. Errors
are addressed with one or
fewer items left out.
Sentence structure flows
well.
Grammar and spelling are all
correct. All errors are corrected
accurately per requirements.
Sentence structure is good. Clear
and concise wording.
Use of appropriate
medical terminology.
Sentences are
concise.
Little to no use of
appropriate medical
terms, phrases, and/or
abbreviations. Need to
review in detail the
resources given to
increase knowledge of
medical
documentation.
Noted several sentences
that could have been
made more effective by
adding medical
terminology. Used
several terms that are
not approved. Sentences
repeat info over and over
with no real emphasis on
goals.
Work does contain several
abbreviations and terms
that were appropriate.
Cont. to look over
resources for further info to
improve paper. May
contain some nonapproved terms. Need to
group items to make more
concise.
Work is very professional in content.
Use of terms and abbreviations are
appropriate and all are acceptable
by the current practice. Can clearly
see you are increasing your
vocabulary. Overall note and
information is presented concisely.
Total:
/16
Comments:
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 16
OTHA 2261 – Clinical II (Adults) – Revised 8/15
Page 17