Assignment: Soap Notes Template
Assignment: Soap Notes Template
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
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Submission Instructions:
Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
Please follow the grading rubric closely. The instructor is very strict and follows rubric closely.
Please use the attached Template
Please discuss a 32 y/o white female complaining of burning and itching in vaginal area. Primary Diagnosis Genital Herpes (initial infection)
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Distinguised Excellent Fair Poor
Subjective
Chief Complaint (Reason for seeking health care) Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points 3 Points 2 Points 0 Points
Demographics
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
History of the Present Illness (HPI)
Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 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) 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)
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Allergies
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)
If allergies are present, students lists type Drug, environemtal factor, herbal, food, latex name and includes severity of allergy OR description of allergy
If allergies are present, students lists only the type of allergy name
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Review of Systems (ROS)
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”
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”
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”
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Objective
Vital Signs
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.)
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.)
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.)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Labs
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.
Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values. does not include the values of lab results or highlight abnormal values.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Medications
Includes a list of all of the patient reported
medications and the medical diagnosis for the medication (including name, dose, route, frequency)
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)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose, route, frequency)
Information is completely missing
4 Points 2 Points 1 Points 0 Points
Screenings
Includes an assessment of at least 5
screening tests
Includes an assessment of at least 4 screening
tests
Includes an assessment of at least 3 screening
tests
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Past Medical History
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current
Includes each medical diagnosis but does not
include year of diagnosis or whether the diagnosis is active or current
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Past Surgical History
Includes, for each surgical procedure, the
year of procedure and the indication for the procedure
Includes, for each surgical procedure, the year of procedure OR indication of the procedure Includes, for each surgical procedure but not the year of procedure or indication of the procedure
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Family History
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Social History
Includes all of the following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Includes 10 of the 11 following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Includes 9 or less of the following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Physical Examination
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint
Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Assessment
Diagnosis
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal diagnosis
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Differential Diagnosis
Includes at least 3 differential diagnoses for the principal diagnosis
Includes 2 differential diagnoses for the principal diagnosis
Includes 1 differential diagnosis for the principal diagnosis
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Plan
Pharmacologic treatment plan
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.
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.
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.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Diagnostic/Lab Testing
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”
Includes appropriate diagnostic testing less than 50% of the time.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Education
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.
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.
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.
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Anticipatory Guidance
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)) 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)) 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))
Information is completely missing
4 Points 2 Points 1 Points 0 Points
Follow up plan
Includes recommendation for follow up,
including time frame (i.e. x # of days/weeks/months)
Includes recommendation for follow up, but does
not include time frame (i.e. x # of days/weeks/months)
Does not include follow up plan
4 Points 2 Points 0 Points 0 Points
Writing
References
High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing
3 Points 2 Points 1 Points 0 Points
Grammar
Free of grammar and spelling errors Writing mechanics need more precision and attention to detail Writing mechanics need serious attention
3 Points 2 Points 0 Points 0 Points
