Module 7 Assignment i Cont’d.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| S = | Subjective data: Patient’s Chief Complaint (CC). |
| O = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| A = | Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
| P = | Plan: Treatment, diagnostic testing, and follow up |
Submission Instructions:
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
- Complete and submit the assignment using the appropriate template in MS Word
Grading Rubric
Your assignment will be graded according to the grading rubric.
| SOAP Notes Rubric | ||
|---|---|---|
| Criteria | Ratings | Pts |
| Chief Complaint (Reason for seeking health care) – S |
4 pts Distinguished Includes a direct quote from patient about presenting problem 3 pts Excellent Includes a direct quote from patient and other unrelated information 2 pts Fair Includes information but information is NOT a direct quote 0 pts Poor Information is completely missing |
/ 4 pts |
|
Demographics – S |
2 pts Distinguished Begins with patient initials, age, race, ethnicity and gender (5 demographics) 1.5 pts Excellent Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender) 1 pts Fair Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) 0 pts Poor Information is completely missing |
/ 2 pts |
|
History of the Present Illness (HPI) – S |
5 pts Distinguished Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 3 pts Excellent Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 2 pts Fair Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 0 pts Poor Information is completely missing |
/ 5 pts |
|
Allergies – S |
2 pts Distinguished Includes NKA (including = Drug, Environemental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy) 1.5 pts Excellent If allergies are present, students lists type Drug, environemtal factor, herbal, food, latex name and includes severity of allergy OR description of allergy 1 pts Fair If allergies are present, students lists only the type of allergy name 0 pts Poor Information is completely missing |
/ 2 pts |
|
Review of Systems (ROS) – S |
12 pts Distinguished Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits� and “denies� 6 pts Excellent Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits� and “denies� 3 pts Fair Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits� and “denies� 0 pts Poor Information is completely missing |
/ 12 pts |
|
Vital Signs – O |
2 pts Distinguished Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1.5 pts Excellent Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1 pts Fair Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 0 pts Poor Information is completely missing |
/ 2 pts |
|
Labs – O |
3 pts Distinguished Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed. 2 pts Excellent Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values. 1 pts Fair Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values. 0 pts Poor Information is completely missing |
/ 3 pts |
|
Medications – O |
4 pts Distinguished Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency) 2 pts Excellent Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency) 1 pts Fair Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency) 0 pts Poor Information is completely missing |
/ 4 pts |
|
Screenings – O |
3 pts Distinguished Includes an assessment of at least 5 screening tests 2 pts Excellent Includes an assessment of at least 4 screening tests 1 pts Fair Includes an assessment of at least 3 screening tests 0 pts Poor Information is completely missing |
/ 3 pts |
|
Past Medical History – O |
3 pts Distinguished Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current 2 pts Excellent Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current 1 pts Fair Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current 0 pts Poor Information is completely missing |
/ 3 pts |
|
Past Surgical History – O |
3 pts Distinguished Includes, for each surgical procedure, the year of procedure and the indication for the procedure 2 pts Excellent Includes, for each surgical procedure, the year of procedure OR indication of the procedure 1 pts Fair Includes, for each surgical procedure but not the year of procedure or indication of the procedure 0 pts Poor Information is completely missing |
/ 3 pts |
|
Family History – O |
3 pts Distinguished Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 2 pts Excellent Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 1 pts Fair Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 0 pts Poor Information is completely missing |
/ 3 pts |
|
Social History – O |
3 pts Distinguished Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. 2 pts Excellent Includes 10 of the 11 following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. 1 pts Fair Includes 9 or less of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. 0 pts Poor Information is completely missing |
/ 3 pts |
|
Physical Examination – O |
12 pts Distinguished Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint 6 pts Excellent Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint 3 pts Fair Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint 0 pts Poor Information is completely missing |
/ 12 pts |
|
Diagnosis – A |
5 pts Distinguished Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) 3 pts Excellent Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority 2 pts Fair Includes an inaccurate diagnosis as the principal diagnosis 0 pts Poor Information is completely missing |
/ 5 pts |
|
Differential Diagnosis – A |
5 pts Distinguished Includes at least 3 differential diagnoses for the principal diagnosis 3 pts Excellent Includes 2 differential diagnoses for the principal diagnosis 2 pts Fair Includes 1 differential diagnosis for the principal diagnosis 0 pts Poor Information is completely missing |
/ 5 pts |
|
Pharmacologic treatment plan – P |
5 pts Distinguished Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment�. The plan includes ALL of the following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. 3 pts Excellent Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment�. The plan includes 4 of the following 7: the drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. 2 pts Fair Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment�. The plan includes less than 4 of the following: the drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. 0 pts Poor Information is completely missing |
/ 5 pts |
|
Diagnostic/Lab Testing – P |
5 pts Distinguished Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time� 3 pts Excellent Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time� 2 pts Fair Includes appropriate diagnostic testing less than 50% of the time. 0 pts Poor Information is completely missing |
/ 5 pts |
|
Education – P |
5 pts Distinguished Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives. 3 pts Excellent Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives. 2 pts Fair Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives. 0 pts Poor Information is completely missing |
/ 5 pts |
|
Anticipatory Guidance – P |
4 pts Distinguished Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) 2 pts Excellent Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) 1 pts Fair Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening)) 0 pts Poor Information is completely missing |
/ 4 pts |
|
Follow up plan – P |
4 pts Distinguished Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months) 2 pts Excellent Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months) 0 pts Poor Does not include follow up plan |
/ 4 pts |
|
References |
3 pts Distinguished High level of APA precision 2 pts Excellent Moderate level of APA precision 1 pts Fair Incorrect APA style 0 pts Poor Information is completely missing |
/ 3 pts |
|
Grammar |
3 pts Distinguished Free of grammar and spelling errors 2 pts Excellent Writing mechanics need more precision and attention to detail 0 pts Poor Writing mechanics need serious attention |
/ 3 pts |
| Total Points: 0 | ||