Description
Overview
The goal is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in this week’s learning materials. Review the SOAP Note Rubric.
Instructions
Choose an abnormal finding related to the content that was covered this week. Examples from this week would include: shortness of breath, cough, wheezing, dyspnea on exertion, etc.
Select “WHEEZING” Diagnosis: ASTHMA ATTACK
Develop a focused SOAP note for the abnormal finding. You do not need to find a patient to match this finding. The point is for you to think about what the HPI would be, what the rest of the history may look like, what the objective findings will be, the potential differential diagnoses, and the plan. In other words, you are creating the patient scenario and documenting it in SOAP format. Please be sure to include all relevant information and not just the system the abnormal finding is in.
Refer to the Grading Rubric to see how your work will be assessed.
Unformatted Attachment Preview
SOAP Note Rubric
[SOAP Note Rubric] – 100 Points
Criteria
Exemplary
Exceeds
Expectations
Advanced
Meets Expectations
Intermediate
Needs
Improvement
Novice
Inadequate
Total
Points
Subjective (25 points)
Patient described in
appropriate detail
Patient described in
appropriate detail
1 detail missed in
patient description
25
Concise and clear
chief complaint as
described by patient
Concise and clear
chief complaint as
described by patient
HPI includes all
components with
appropriate detail
HPI missing minor
detail
Chief complaint as
described by
patient, may not
be concise or clear
>2 details missed
in patient
description
Information about the
patient (3 points)
Name (initials only);
age, and gender
Source of
information; note
relationship to
patient, if relevant
Reliability of
information
Chief Complaint (1 point)
History of Presenting
Illness (8 points)
Location
Quality
Quantity or severity
Timing (onset,
duration,
frequency)
Setting in which it
occurs
Factors that
aggravate or relieve
the symptoms
Associated
manifestations
Review of Focus System(s)
(5 points)
Comprehensive
review of focus
system(s) includes
pertinent negatives
Name, dose, route,
and frequency of
prescribed and over–
the–counter
medications noted,
including
compliance;
Allergies to
medications and
reaction noted
Comprehensive
health history is
appropriate to
reason for visit and
includes pertinent
negatives
Comprehensive
review of focus
system(s)
Name, dose, route,
and frequency of
prescribed and over–
the–counter
medications noted,
including compliance;
Allergies to
medications and
reaction noted
Comprehensive
health history is
appropriate to reason
for visit
Chief complaint
not identified,
concise, or clear
HPI missing 1
component or
significant detail
HPI missing >2
components and
significant detail
Review of focus
system missing 1–
2 components
Review of focus
system(s) missing
>3 components
Medication history
missing 1–2
components
Medication history
missing >3
components
Health history not
appropriate for
reason for visit or
missing 1–2
components
Health history
missing >3
components
17 points
19 points
22 points
25 points
Medications/Allergies (3
points)
History (5 points)
Past Medical
History
Past Surgical
History
Family History
Social History
Health Maintenance
Practices
Objective (30 points)
Physical exam includes
appropriate areas for Chief
Complaint, History of
Presenting Illness, and
Review of Systems (20
points)
Appropriate techniques of
examination used to
identify pertinent findings
(10 points)
Appropriate areas
and systems
included in physical
assessment
Comprehensive
techniques of
observation,
palpation,
percussion, and
auscultation noted
including special
assessments as
appropriate
30 points
Missing 1 expected
area of assessment
Appropriate
techniques of
examination used but
special assessment
technique missed
26 points
Missing 2
expected areas of
assessment
Missing >3
expected areas of
assessment
One basic
technique of
examination
missed
>2 techniques of
examination
missed
23 points
20 points
30
Assessment (20 points)
Differential diagnoses are
supported by subjective
and objective findings (15
points)
Scholarly resources
support differential
diagnoses (5 points)
Three differential
diagnoses are
supported by
findings and include
worst case scenario
Rationale for
differential diagnoses
provided by scholarly
resources
20 points
Plan (15 points)
Comprehensive plan to
address likely differential
diagnosis includes (9
points)
Diagnostic testing
Pharmacologic
intervention
Non–
pharmacologic
intervention
Referrals
Patient education
Follow–up
Comprehensive plan
includes all
components
Appropriate and
current guidelines
cited
15 points
Three differential
diagnoses include
worst case scenario
but one diagnosis
may not be fully
supported by findings
Rationale for
differential diagnoses
provided by scholarly
resources
17 points
Plan missing 1 of the
identified components
Appropriate and
current guidelines
cited
13 points
Differential
diagnoses may or
may not include
worst case
scenario and 2
differential
diagnoses not
supported by
findings
3
of the identified
components
Guidelines are not
current or
appropriate for
identified problem
Guidelines for
plan not cited
20
15
10 points
12 points
Plan is supported by
appropriate and current
practice guidelines (6
points)
Documentation (10 points)
Documentation follows
SOAP template, is logical,
and in correct format (10
points)
Logical and
systematic
organization of data
Logical and
systematic
organization of data
Minor errors in
organization of
data
Correct terminology,
spelling, and
grammar
Terminology, spelling,
grammar or format
errors (1–3)
Scholarly resources
noted in correct APA
format
8 points
Terminology,
spelling, grammar,
or format errors
(4–5)
7 points
Disorganized flow
of data
10
Terminology,
spelling, grammar
or format errors
(>5)
6 points
10 points
Total Points
100
Purchase answer to see full
attachment
