This week, you will submit a SOAP note.

  1. Select a “patient” (friend or family member) on whom to perform a complete H&P.
  2. NOTE: DO NOT USE REAL NAMES OR INITIALS OR OTHERWISE IDENTIFY YOUR “PATIENT.” FAILURE TO MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
  3. Using the format specified below, write a 1 to 2 page SOAP note on your “patient.” The HPI should be presented in a paragraph, and the rest of the data including the ROS should be presented in a list format.
  4. Collect only the information that is pertinent to the chief complaint of the patient to include in your SOAP note. Aim for a single page using normal margins and format.
  5. The SOAP Note must contain all required elements as outlined in the rubric below.
  6. You must self-score your SOAP note using the rubric and attach it to the assignment.Subjective Data· Biographic Data:– Age/race/gender, date, occupation, language/communication needs.

    · Source – and reliability

    · Chief Complaint (reason for seeking care)- make every attempt to use patient’s own words.

    · History of Present Illness (HPI)- complete, clear, chronological account of events prompting patient to seek care. Use OLDCARTS or PQRST to gather data but do not include acronym in HPI. Document in paragraph format.

    · Past Medical History (PMH)- childhood, adult illnesses, serious illnesses/hospitalizations, obstetric hx, Immunizations, last exam

    · Allergies, medication, food, environmental

    · Medications– Rx, OTC, herbal, etc.

    · Family History– write a genogram diagram or outline; age, health, age, and cause of death of each family member going back three generations.

    · Personal and Social History– interests, support systems, occupation, highest level of education, job history, financial situation, spiritual beliefs, lifestyle, alternative health care practices, sexual and obstetric history.

    · Review of Systems (ROS)- series of questions from head to toe. Must be in the following order – include health promotion practices:

    · General Survey

    · Integumentary

    · Head, Eyes, Ears, Nose, and Throat

    · Neck/thyroid

    · Breasts and axillary lymph nodes

    · Respiratory

    · Cardiovascular

    · Peripheral vascular

    · Gastrointestinal

    · Genitourinary

    · Genital/Reproductive system

    · Sexual health

    · Musculoskeletal

    · Neurological (must include reflexes on PE)

    · Hematologic

    · Endocrine

    · Functional assessment – include activities of daily living

    · Self-esteem/self-concept

    · Activity/exercise

    · Sleep/rest/nutrition, include

    · Nutritional status assessment- identify if patient is at risk for malnutrition or over nutrition

    · Interpersonal relationships

    · Spiritual resources

    · Coping and stress management

    · Personal habits – alcohol, tobacco, street drugs

    · Environment/Hazards

    · Intimate partner violence

    · Occupational health

    · Perception of health

    · Developmental Competence – children, pregnant women, older adult

    Objective data

    · Physical Examination (PE)

    · General Survey

    · Integumentary

    · Head, Eyes, Ears, Nose, and Throat

    · Neck/thyroid

    · Breasts and axillary lymph nodes

    · Respiratory

    · Cardiovascular

    · Peripheral vascular

    · Gastrointestinal

    · Genitourinary

    · Genital/Reproductive system

    · Sexual health

    · Musculoskeletal

    · Neurological (must include reflexes on PE)

    · Hematologic

    · Endocrine

    Assessment

    · Diagnosis with rationale

    · Differential diagnosis with rationales

    Plan

    · Dx plan – include diagnostic tests needed (lab, x-ray, etc.)

    · Tx plan – include recommended treatment – cite national guidelines

    · Patient education – including specific medication teaching

    · Referral/Follow up

    · Health Maintenance – include health promotion recommendations from AHRQ (ePSS app) according to age/gender/conditions

    Week 8 SOAP Note Assignment

    profileygalan83

    SOAPNOTERUBRIC.docx
    SOAP NOTE RUBRIC

    0-5

    points

    6-10

    points

    11-15

    points

    16-20

    points

    21-25

    points

    Student

    Score

    SUBJ Data is not organized. Objective is mixed into the subjective data. Data is not well organized. The complete pre-conceived differential considered is incomplete. Data is missing. Data is well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. It is clear to the reader that information is gathered to include/exclude options in the differential. Too much extraneous data Data is well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Little extraneous data may be present. Complete, concise, relevant without extraneous data. All data needed to support differential is present with no extraneous data.
    OBJ Subjective data is included. Not all relevant exams were done. All relevant exams were done but not thoroughly. All relevant exams were done thoroughly but extraneous exams were also done. Complete, concise, well-organized and well-written.
    DDX No assessment provided. Assessment present but mixed with other problems that are not reflective of S/0. Appears to be preceptor’s diagnosis. Assessment reflects information in S/O data but does not include correct differential. Each problem identified has a differential that is reflected in S/O. Differential/problems are not prioritized correctly. Assessment and prioritized differential accurate and supported. Demonstrates exceptional critical thinking.
    PLAN No Plan provided Plan present but does not address all problems identified. Appears to be preceptor’s plan. Plan addresses all problems but some interventions are not evidence-based. Plan is organized but fails to address any of: barriers to compliance needs for education plan for preventive complete plan for follow up. Plan is complete prioritized, and demonstrates exceptional critical thinking. Counseling on despair was accomplished.
    Total Score:

     

 
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