Description
SOAP
SOAP Notes 3
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.
Rubric
SOAP Notes Rubric
SOAP Notes Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeChief 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
This criterion is linked to a Learning OutcomeDemographics – 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
This criterion is linked to a Learning OutcomeHistory 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
This criterion is linked to a Learning OutcomeAllergies – 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
This criterion is linked to a Learning OutcomeReview 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
This criterion is linked to a Learning OutcomeVital 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
This criterion is linked to a Learning OutcomeLabs – 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
This criterion is linked to a Learning OutcomeMedications – 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
This criterion is linked to a Learning OutcomeScreenings – 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
This criterion is linked to a Learning OutcomePast 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
This criterion is linked to a Learning OutcomePast 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
This criterion is linked to a Learning OutcomeFamily 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
This criterion is linked to a Learning OutcomeSocial 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
This criterion is linked to a Learning OutcomePhysical 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
This criterion is linked to a Learning OutcomeDiagnosis – 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
This criterion is linked to a Learning OutcomeDifferential 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
This criterion is linked to a Learning OutcomePharmacologic 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
This criterion is linked to a Learning OutcomeDiagnostic/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
This criterion is linked to a Learning OutcomeEducation – 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
This criterion is linked to a Learning OutcomeAnticipatory 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
This criterion is linked to a Learning OutcomeFollow 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
This criterion is linked to a Learning OutcomeReferences
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
This criterion is linked to a Learning OutcomeGrammar
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: 100
Unformatted Attachment Preview
SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health:
Excellent
Good
Fair Poor
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: ____________________________________________________________
Copyright © MVJ 2018
Social history:
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
Copyright © MVJ 2018
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
Copyright © MVJ 2018
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
3.
Principal Diagnoses
1.
Copyright © MVJ 2018
2.
Plan
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Copyright © MVJ 2018
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
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: ____________________________________________________________
Copyright © MVJ 2018
Copyright © MVJ 2018
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: ___ 9/13/23_____________________
Patient Initials: _M.I____ Gender: Female Age: _79 years _ Race: Hispanic__ Ethnicity _Hispanic___
Reason for Seeking Health Care: M.I. States “I am worried about my heart health and cholesterol levels,
especially with my age.”
HPI: M.I. is a 79-year-old Hispanic woman who came for follow up of her cholesterol levels.
She is concerned since she formerly had high cholesterol levels and wants to know how they are
today.
Allergies(Drug/Food/Latex/Environmental/Herbal): The patient denies any history of allergies.
Current perception of Health: Good
Past Medical History
• Major/Chronic Illnesses: Hypertension controlled with medication.
• Trauma/Injury: Fractured wrist in 2018, healed.
• Hospitalizations: Hospitalized in 2018 for wrist surgery.
Past Surgical History: Wrist surgery in 2018.
Medications: Lisinopril 20 mg po daily.
Family History: Mother died of a heart attack at 85. Father had DM type 2 and passed at 90.
Brother has DM type 2 and Hypertension. Sister has Hypertension.
Social history:
Lives: In an apartment with an elevator. Marital Status: Widowed Employment Status:
Retired. Previous occupation was an accountant.
Current/Previous occupation type: Full time.
Copyright © MVJ 2018
Exposure to Smoke: Denies, never smoked.
ETOH: Denies any alcohol consumption.
Recreational Drug Use: patient denies any use of recreational drugs
Sexual orientation: Heterosexual
Sexual Activity: not currently sexually active
Contraception Use: Not applicable
Family Composition: Lives alone, family lives nearby
Health Maintenance
Screening Tests:
•
Bone Density Scan: Last checked on 07/01/2022, Results within normal range.
•
Colonoscopy: Last procedure on 07/10/2022, No polyps found.
•
Mammography: Last done on 07/15/2022, Results negative for abnormalities.
•
Blood Pressure: Last checked on 08/09/2023, 118/76 mm/Hg.
•
Cholesterol Level: Last checked on 08/09/2023, 205 mg/dl
Exposures: Patient states some of her family members have been sick lately with flu, but she
denies any respiratory flu like symptoms.
Immunization HX: The patient has maintained an up-to-date immunization record, as per the
information available in her health profile.
Review of Systems:
General: Patient is alert and oriented, with no evident signs of acute distress.
HEENT: Denies visual changes, sore throat, or congestion.
Copyright © MVJ 2018
Neck: Denies neck pain, stiffness, or swelling.
Lungs: Patient admits occasional shortness of breath during activities, but denies any chronic
cough, wheezing, or hemoptysis.
Cardiovascular: Denies chest discomfort, swelling in legs, or syncope.
Breast: Denies any recent changes such as lumps, discharge, or discomfort.
GI: Patient denies experiencing nausea, vomiting, diarrhea, or blood in the stool.
GU: patient denies flank pain, urinary urgency, discomfort, or discharge.
Neuro: Patient denies any history of migraines or recent headaches.
Musculoskeletal: Patient denies any joint pains or stiffness. Admits to mild muscle pains in
activities involving walking for a moderate time.
Activity & Exercise: The patient is moderately active, admits walking regularly in the
neighborhood.
Psychosocial: Patient denies feelings of depression or anxiety.
Derm: Patient denies rashes, ulcers, or itching.
Nutrition: Admits to having fried foods and pork often in her diet but is attempting to better her
diet.
Sleep/Rest: Admits to sleeping approximately 6 hours each night without interruptions.
LMP: NA, patient admits she is postmenopausal.
STI Hx: denies any known history of sexually transmitted infections
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Physical Exam
BP: 122/80 mmHg (Seated)
HR: 82 beats per minute
RR: 18 breaths per minute
Temperature: 98.5°F Oral
Height: 5’4″
Weightt: 145 lb
BMI (percentile) __24.9 ___
Pain: Denies pain
General: M.I. is a alert and oriented to person, place, and time. Well groomed.
HEENT: Pupils are equal, round and reactive to light. Nares are patent. Throat is without
erythema or exudate. Oral mucosa is intact and moist with no lesions.
Neck: No JVD, or masses observed.
Pulmonary: Respirations are regular, chest expansion symmetrical, lung sounds clear in all lobes,
no wheezing.
Cardiovascular: Regular heart rhythm and rate, no murmur auscultated. pulses are 2+ and
symmetrical in all extremities. Capillary refill is less than 3 seconds.
Breast: No tenderness, lesions, or lumps noted.
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GI: Abdomen is soft and flat, no visible scars. Bowel sounds are present in all four quadrants. No
tenderness.
Male/female genital: N/A
GU: No distention of bladder noted.
Neuro: alert and oriented. Strength 5/5 in all muscle groups. Cranial nerves II – XII intact.
Musculoskeletal: No swelling, deformities, or limitation in any major joint.
Derm: No significant rashes, moles, or suspicious lesions.
Psychosocial: speech is clear, and her affect is appropriate to the situation, pleasant and
cooperative.
Misc. NA
Plan:
Differential Diagnoses
1. Atherosclerosis
2. Hyperlipidemia
3. Hypothyroidism
Principal Diagnoses
1. Hyperlipidemia
Plan
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Diagnosis: Hyperlipidemia
Diagnostic Testing: Thyroid function tests to rule out hypothyroidism as a cause for elevated
cholesterol.
Pharmacological Treatment: Start taking a statin, such as 10mg of atorvastatin daily.
Medication Cost: CVS Pharmacy 10mg atorvastatin 30 tablets $24.74
Education: M.I. will be educated on how to keep a heart-healthy diet, maintain a regular
exercise routine, and strictly adhere to the dosages of her medicine. She will also be
educated on the side effects of Statins which may cause muscular soreness and weakness,
so she must watch for such symptoms. In addition, she will be scheduled follow up
appointments to monitor her cholesterol levels.
Referrals: No
Follow-up: In 3 months to check the efficacy of the medication and review cholesterol levels.
Anticipatory Guidance: M.I. should do more aerobic activity such as walking for 30 minutes
daily five days a week, stay away from meals rich in saturated fats, and increase her intake
of fruits and vegetables in order to improve cholesterol level.
Signature (with appropriate credentials): Michael Gomez, RN BSN FNP
esignature
Copyright © MVJ 2018
Student
Cite current evidenced based guideline(s) used to guide care (Mandatory): National Heart,
Lung, and Blood Institute guidelines for cholesterol management.
DEA#: 101010101
STU Clinic
Tel: (000) 555-1234
Patient Name: (Initials)_ M.I _________
FAX: (000) 555-12222
Age ___79 Years_____
Date: __09/13/2023_
RX ____ Atorvastatin 10mg
SIG: 1 tablet by mouth once daily at bedtime.
Dispense: 30
Refill: 2_
No Substitution
Signature: __ Michael Gomez, RN BSN FNP Student esignature
Copyright © MVJ 2018
LIC# 10000000
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