Description
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template belowFor 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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Distinguised
Excellent
Fair
Poor
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
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
3 Points
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
2 Points
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
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
If allergies are present, students lists only the
type of allergy name
Information is completely missing
1 Points
0 Points
Subjective
Chief Complaint (Reason for seeking
health care)
Demographics
History of the Present Illness (HPI)
Allergies
Includes NKA (including = Drug,
If allergies are present, students lists type Drug,
Environemental, Food, Herbal, and/or Latex
environemtal factor, herbal, food, latex name and
or if allergies are present (reports for each
includes severity of allergy OR description of
severity of allergy AND description of
allergy
allergy)
2 Points
Review of Systems (ROS)
1.5 Points
Includes 3 or fewer assessments for each body
Includes 3 or fewer assessments for each body
Includes a minimum of 3 assessments for
each body system and assesses at least 9 system and assesses 5-8 body systems directed to system and assesses less than 5 body systems
chief complaint AND uses the words “admits” directed to chief complaint OR student does not
body systems directed to chief complaint
use the words “admits” and “denies”
and “denies”
AND uses the words “admits” and “denies”
12 Points
6 Points
3 Points
0 Points
Information is completely missing
0 Points
Objective
Vital Signs
Includes all 8 vital signs, (BP (with patient
Includes 7 vital signs, (BP (with patient position), Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with
HR, RR, temperature (with Fahrenheit or Celsius position), HR, RR, temperature (with Fahrenheit
Fahrenheit or Celsius and route of
and route of temperature collection), weight,
or Celsius and route of temperature collection), Information is completely missing
temperature collection), weight, height, BMI
height, BMI (or percentiles for pediatric
weight, height, BMI (or percentiles for pediatric
(or percentiles for pediatric population) and
population) and pain.)
population) and pain.)
pain.)
2 Points
Labs
Medications
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.
3 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
1.5 Points
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
1 Points
0 Points
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
Information is completely missing
highlight abnormal values.
2 Points
1 Points
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)
0 Points
Information is completely missing
Screenings
Past Medical History
4 Points
Includes an assessment of at least 5
screening tests
2 Points
Includes an assessment of at least 4 screening
tests
3 Points
2 Points
Includes (Major/Chronic, Trauma,
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis either year of diagnosis OR whether the diagnosis
is active or current
is active or current
3 Points
Past Surgical History
Family History
Social History
0 Points
Information is completely missing
1 Points
0 Points
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current
Information is completely missing
1 Points
0 Points
Includes, for each surgical procedure, the
Includes, for each surgical procedure, the year of Includes, for each surgical procedure but not the
year of procedure and the indication for the
procedure OR indication of the procedure
year of procedure or indication of the procedure Information is completely missing
procedure
3 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
3 Points
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.
3 Points
Physical Examination
2 Points
1 Points
Includes an assessment of at least 3 screening
tests
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
12 Points
2 Points
1 Points
0 Points
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
2 Points
1 Points
0 Points
Includes 10 of the 11 following: tobacco use,
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
status, current/previous occupation, sexual
Information is completely missing
orientation, sexually active, contraceptive use,
orientation, sexually active, contraceptive use,
and living situation.
and living situation.
2 Points
1 Points
0 Points
Includes a minimum of 3 assessments for each
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems body system and assesses at least 4 body systems Information is completely missing
directed to chief complaint
directed to chief complaint
6 Points
3 Points
0 Points
Assessment
Diagnosis
Includes a clear outline of the accurate
Includes a clear outline of the accurate diagnoses
principal diagnosis AND lists the remaining
Includes an inaccurate diagnosis as the principal
addressed at the visit but does not list the
Information is completely missing
diagnoses addressed at the visit (in
diagnosis
diagnoses in descending order of priority
descending priority)
5 Points
Differential Diagnosis
3 Points
2 Points
0 Points
Includes at least 3 differential diagnoses for Includes 2 differential diagnoses for the principal Includes 1 differential diagnosis for the principal
Information is completely missing
the principal diagnosis
diagnosis
diagnosis
5 Points
3 Points
Plan
2 Points
0 Points
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Includes a detailed pharmacologic treatment
Includes a detailed pharmacologic treatment plan
Includes a detailed pharmacologic treatment plan
plan for each of the diagnoses listed under
for each of the diagnoses listed under
for each of the diagnoses listed under
“assessment”. The plan includes ALL of
“assessment”. The plan includes less than 4 of
“assessment”. The plan includes 4 of the
the following: drug name, dose, route,
the following: the drug name, dose, route,
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
frequency, duration and cost as well as
frequency, duration and cost as well as education
education related to pharmacologic agent. If
related to pharmacologic agent. If the diagnosis
related to pharmacologic agent. If the diagnosis is
the diagnosis is a chronic problem, student
is a chronic problem, student includes
a chronic problem, student includes instructions
includes instructions on currently prescribed
instructions on currently prescribed medications
on currently prescribed medications as above.
medications as above.
as above.
Information is completely missing
5 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
5 Points
3 Points
2 Points
0 Points
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
3 Points
2 Points
0 Points
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
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
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
4 Points
2 Points
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
2 Points
1 Points
0 Points
Does not include follow up plan
0 Points
0 Points
Moderate level of APA precision
Incorrect APA style
Information is completely missing
3 Points
2 Points
1 Points
0 Points
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
Writing
References
Grammar
High level of APA precision
0 Points
SOAP Note
Encounter Date:
Preceptor/s Name:
Student Name:
Faculty Name: ST. Thomas University
Course Number: NUR 509CL – Advanced FNP: Clinical III – 2023 Fall 1
Patient Demographics:
Gender: Female
Race: White
Age Range: 63 years
Ethnicity: White
Reason for Seeking Health Care: Follow-Up (Routine). “I am having a burning sensation on my upper
back. Sometimes it itches”
HPI: G.H. is a pleasant 63-year-old woman. Good historian, AOX 3. Spanish-speaking mostly.
Came into the clinic complaining of a burning sensation in her right upper back. The patient said
she tried to get the Zoster vaccine last week but was declined. She believes she has had it for
about two weeks. This is the first time she has been seen for this. She had a history of chicken
pox when she was little. The patient states the pain is an 8 out of 10 when she starts to itch. The
patient takes Ibuprofen 300 mg as needed for pain. Ibuprofen does not help alleviate the pain.
Pain occurs mainly at nighttime, which causes her to have a hard time sleeping. Treatment
options are discussed at the bedside. Labs were drawn, and the patient will be informed of the
results when available. The patient should follow up in a few weeks or sooner if needed.
Allergies (Drug/Food/Latex/Environmental/Herbal): No known allergies.
Current perception of Health: Good.
Past Medical History
• Major/Chronic Illnesses: Tobacco dependence, Chickenpox as a child
• Trauma/Injury:
• Hospitalizations: Gallbladder Removal
Past Surgical History: Gallbladder removal at age 34.
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Family History: Father: Colon cancer diagnosed at age 65. Mother: HTN Maternal
Grandmother- Breast Cancer at the age of 54, Paternal Grandfather: Diabetes type 1
Medications: Ibuprofen 200mg q 4-6 hours as needed for pain relief.
Social History:
Lives: House
Marital Status: Widowed
Employment Status: Unemployed (Retired)
Current/Previous occupation type: Retired Teacher
Exposure to: Smoke- Smoker since she was 15 years old.
Recreational Drug Use: No
Sexual orientation: Homosexual
Sexual Activity: Straight
Contraception Use: Condoms
Family Composition: Family
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Health Maintenance
Exposures: Smoke and sun
Immunization H.X.: Up to date
Screening Tests (Mammogram et al., etc.): Gallbladder removal in 1994
Review of Systems:
General: Alert and Oriented x 3. Denies any recent fever or chills. Denies any fatigue.
HEENT: Head Normal, no mass or lesions noted.
Eyes: Pupils are round and reactive. Ears: No inflammation noted. Ears symmetrical to head.
Conjunctiva White. No changes in vision.
Nose: Septum midline. Throat: No redness noted. Trachea midline
Neck: Symmetrical. No mass or swollen lymph nodes were noted. No neck tenderness noted
Lungs: Symmetrical. No mass was noted.
Cardiovascular: S1 and S2 noted—capillary Refill less than 3 seconds.
Breast: No lymph or swelling.
GI: Active Bowel sounds. Non-tender, soft abdomen. No hernia noted
Male/female genital: No discharge reported.
GU: Normal urine output and color.
Neuro: AOx 3. No tremors, vertigo, or dizziness were noted.
Musculoskeletal: Denies joint pain or swelling. No edema noted. Full movement noted on the
Upper and lower extremities. Normal gait.
Activity & Exercise: Physically active.
Psychosocial: No mental illness. Normal affect and mood.
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Derm: Warm, dry skin. Erythematous vesicles are located in the Right upper quadrant of the
back. The rash covers one dermatome: Thoracic; rash does not cross the midline.
Nutrition: G.H. eats a well-balanced diet with 2 cups of coffee every day
Sleep/Rest: Trouble sleeping due to the burning and itchiness of the vesicles
LMP: Menopause
STI Hx: No STI reported.
Physical Exam
B.P.: 123/67 Right arm, sitting TPR: 98.2 F H.R.: 82 R.R.: 17 Ht.: 5 ft 2 inch
Wt.: 141.2 lbs. BMI (percentile): 25.8 Pain: 5
General: Alert and Oriented x 3. Denies any recent fever or chills. Denies any fatigue.
HEENT: Head Normal, no mass or lesions noted.
Eyes: Pupils are round and reactive. Ears: No inflammation noted. Ears symmetrical to head.
Conjunctiva White. No changes in vision.
Nose: Septum midline. Throat: No redness noted. Trachea midline
Neck: Symmetrical. No mass or swollen lymph nodes
Pulmonary: Lungs clear bilaterally.
Cardiovascular: Normal S1 and S2 sounds. Capillary refill less than 3 seconds
Breast: No lymph or swelling.
GI: Active Bowel sounds. Non-tender, soft abdomen. No hernia noted
Male/female genital: No discharge reported.
GU: Normal urine output and color.
Copyright © MVJ 2018
Neuro: AOx 3. No tremors, vertigo, or dizziness were noted.
Musculoskeletal: Denies joint pain or swelling. No edema noted. Full movement noted on the
Upper and lower extremities. Normal gait.
Derm: Warm, dry skin. Erythematous vesicles are located in the Right upper quadrant of the
back. The rash covers one dermatome: Thoracic; rash does not cross the midline.
Psychosocial: No mental illness. Normal affect.
Misc.:
Significant Data/Contributing.: Glucose: 101, BUN 10, Creatinine 0.89, Sodium 143,
Potassium 3.5, Chloride 102, CO2 25, Calcium 9.6, HGB 13.1, HCT 34.6, Platelet Count 242,
Cholesterol 129, Triglyceride 62, HDL 56, LDL 90, Non-HDL 130, WBC 5.5
Plan:
Differential Diagnoses
1.
2.
3.
Principal Diagnoses
1.
2.
Plan
Diagnosis
Diagnostic Testing:
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Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
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DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
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