Description
Instructions: Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.
( 35 y/o female coming in for her annual physical exam.)
Use the format below for your SOAP note.
Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.
Problem-Focused SOAP Note Format
Demographic Data
Age and gender (must be HIPAA compliant)
Subjective
Chief Complaint (CC): A short statement about why they are there
History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
Family Hx: any history of CA, DM, HTN, MI, CVA?
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Vital Signs
Physical findings listed by body systems, not paragraph form- Highlight abnormal findings
Assessment (the diagnosis)
At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
Plan
Dx Plan (lab, x-ray)
Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
Reference
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
Points: 50
Problem-focused SOAP Note Format
Rubric
Problem-focused SOAP Note Rubric
Problem-focused SOAP Note Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubject
12.5 to >11.5 pts
Accomplished
Symptom analysis is well organized, with C/C, OLDCART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, and relevant with no extraneous data.
11.5 to >10.25 pts
Satisfactory
Symptom analysis well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Some extraneous data present and/or one minor data point missing.
10.25 to >8.64 pts
Needs Improvement
Symptom analysis is not well organized. Data is missing. There is too much extraneous data and/or 2-3 minor data points missing.
8.64 to >0 pts
Unsatisfactory
Symptom analysis is inadequate, is not organized. Objective or other data is mixed into the subjective data. Important data is missing.
12.5 pts
This criterion is linked to a Learning OutcomeObject
12.5 to >11.5 pts
Accomplished
Complete, concise, well organized, and well written and includes pertinent positive and pertinent negative physical findings. Organized by body system in list format. No extraneous data.
11.5 to >10.25 pts
Satisfactory
All relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format.
10.25 to >8.64 pts
Needs Improvement
Omitted important relevant exams and/or not in list format.
8.64 to >0 pts
Unsatisfactory
Omitted important relevant exams and/or subjective data are included. Lacking organization.
12.5 pts
This criterion is linked to a Learning OutcomeAssessment
12.5 to >11.5 pts
Accomplished
Diagnosis and differential dx are correct with ICD code and supported by subjective and objective data.
11.5 to >10.25 pts
Satisfactory
Diagnosis is correct with ICD codes and is supported by subjective and objective data, however, the most accurate differential diagnosis is not listed according to subjective and objective data.
10.25 to >8.64 pts
Needs Improvement
Diagnosis is correct but either does not include ICD code or is missing two or more important differential diagnoses according to the subjective and objective data provided.
8.64 to >0 pts
Unsatisfactory
Diagnosis is not correct, is not provided, or is not reflective of the subjective and objective data provided.
12.5 pts
This criterion is linked to a Learning OutcomePlan
12.5 to >11.5 pts
Accomplished
Plan is organized, complete, and evidence-based according to the National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).
11.5 to >10.25 pts
Satisfactory
Plan is organized, complete, and evidence-based according to the National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching but may be missing 1-2 minor points.
10.25 to >8.64 pts
Needs Improvement
Plan is less organized and not based on evidence according to the National Standards of Care. Does not address each diagnosis or may not be individualized to the specific patient. Missing medication teaching or one of the 5 components.
8.64 to >0 pts
Unsatisfactory
No Plan is provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching.
12.5 pts
Total Points: 50
