Description
Submit a Problem-Focused SOAP note here for grading. You must use an actual patient from your clinical practicum. Review the rubric for more information on how your assignment will be graded. Be sure to use the SOAP note template for your program and view the rubric associated with your program for details on how your assignment will be graded.Patient: 85 y.o. FEMALEName: D.S.Came in for burning and painful urination.THE REST CAN BE MADE UP.PLEASE FOLLOW THE RUBRIC AS MAX
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FNP/AGPC-NP/AGAC-NP SOAP Note Rubric
Criteria
S
(Subjective)
Ratings
Points
10
points
10 points
Accomplished
Symptom analysis is
well organized, with
C/C, OLD CART,
pertinent negatives,
and pertinent
positives. All data
needed to support
the diagnosis &
differential are
present. Is complete,
concise, and relevant
with no extraneous
data.
5 points
Satisfactory
Symptom analysis
well organized with
C/C, OLD CART,
pertinent negatives,
and pertinent
positives. Some
extraneous data is
present and/or one
minor data point
missing.
2.5 points
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
0 points
Unsatisfactory
Symptom analysis
is inadequate, is not
organized.
Objective or other
data is mixed into
the subjective data.
Important data is
missing.
O
(Objective)
10 points
Accomplished
Complete, concise,
well organized, well
written, and includes
pertinent positive
and pertinent
negative physical
findings. Organized
by body system in
list format. No
extraneous data.
5 points
Satisfactory
All relevant exams
were done
thoroughly but
extraneous exams
were also done. It is
somewhat organized
in list format.
2.5 points
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.
0 points
Unsatisfactory
Omitted important
relevant exams
and/or subjective
data are included.
Lacking
organization.
10
points
A
(Assessment)
10 points
Accomplished
Diagnosis and
differential dx are
correct, include ICD
code, and are
supported by
subjective and
objective data.
2.5 points
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.
0 points
Unsatisfactory
Diagnosis is not
correct, is not
provided or is not
reflective of the
subjective and
objective data
provided.
10
points
P
(Plan)
10 points
Accomplished
Plan is organized,
complete and
supported with 2
evidence-based
references.
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).
5 points
Satisfactory
Diagnosis is correct
with ICD codes and
is supported by
subjective and
objective data.
Differential
diagnosis was
inaccurate based on
subjective and
objective data.
5 points
Satisfactory
Plan is organized,
complete and
evidence-based
according to
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.
2.5 points
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.
0 points
Unsatisfactory
No Plan provided
or is not organized.
Does not address
all diagnoses
identified and/or
does not include all
5 components of
plan, including
medication
teaching.
10
points
Total
40
points
FNP SOAP Note Template
Use this template for Comprehensive Notes (H&Ps) and Problem-Focused Notes
(Episodic/progress notes). For the Problem-Focused Notes, only include pertinent
problem-focused information related to the chief concern (CC).
Demographic Data
o
o
Patient age and gender identity
MUST BE HIPAA compliant
Subjective
Chief Complaint (CC)
O
O
Place the complaint in Quotes
Brief description -only a few words and in the patient’s words … “My chest
hurts,” “I cannot breath,” or “I passed out,” etc.
History of Present Illness (HPI) – the reason for the appointment today
Use the OLD CARTS acronym to document the eight elements of a chief
concern (CC): Onset, Location/radiation, Duration, Character, Aggravating
factors, Relieving factors, Timing, and Severity)
O Briefly describe the general state of health prior to the problem.
O Are Activities of Daily Living (ADL) impacted by the current problem?
O
PAST MEDICAL HISTORY:
O List current and past medical diagnoses
PAST SURGICAL HISTORY:
O List all past surgeries
FAMILY HISTORY:
O Include medical/psychiatric problems to include 3 generations (parents,
grandparents, siblings, or direct relatives.
CURRENT MEDICATIONS:
O Include current prescription(s), over-the-counter medications, herbal/alternative
medications as well as vitamin/supplement use.
ALLERGIES: Include medications, foods, and chemicals such as latex.
IMMUNIZATIONS HISTORY: list current immunization status and address deficiency
PREVENTATIVE HEALTH HISTORY: (See Table below – Appendix A)
SOCIAL HISTORY:
Include nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit
drug use), sexual history/preference, financial problems, legal issues, kids, and
history of abuse, including sexual, emotional, or physical.
O Employment/Education: occupation (type), exposure to harmful agents,
highest school achievement
O
REVIEW OF SYSTEMS:
O A ROS is a question-seeking inventory by body systems to identify signs
and/or symptoms that the patient may be experiencing or has experienced
that may or may not correlate with the CC.
*If a + finding is found not related to the cc this may represent an additional
problem that will need to be detailed in the HPI.
O Must include any physical complaint(s) by the body system that is relevant to
the treatment and management of the current concern(s). List only the
pertinent body systems specific to the CC.
O Remember to include pertinent positive and negative findings when detailing
the ROS related to a chief concern (cc).
O Do not repeat the information provided in HPI
O Use the format below when detailing the ROS
ROS:
General:
Eyes:
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
Objective
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure. Heart rate (regular or irregular). Respirations. SaO2 (on
room air or O2). Temperature. Weight. Height.
*Document the presence of any internal/external devices (IV, Central lines, NGTs, G-tubes,
Ostomies, urinary catheters) and dates of placement.
General:
Eyes:
Ears, nose, mouth & throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Skin & Breasts:
Musculoskeletal:
Allergic:
Immunologic:
Endocrine:
Hematopoietic/Lymphatic:
Genitourinary:
Neurological:
Psychiatric/Mental Status:
Pertinent Diagnostic Test Results:
Assessment (Diagnosis)
Differential Diagnosis (DDx)
O
Include two (2) differential diagnoses you considered but did not select as the
final diagnosis. Why were these 2 diagnoses not selected? Support with
pertinent positive and negative findings for each differential with an evidencebased guideline(s) (required).
Working or Final Diagnosis:
O Final or working diagnosis (1) (including ICD-10 code)
O Provide a rational explanation supported by evidenced-based guidelines
(required). List the pertinent positive and negative symptoms/signs that
support your final diagnosis.
Plan
Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic
Pharmacologic -include full prescribing information for each medication(s)
ordered
O Refill Provided: Include full prescribing information for each medication(s)
refilled and the correlating diagnosis related to the refill.
O
Patient Education:
O Include specific education related to each medication prescribed.
O Was risk versus benefit of current treatment plan addressed for medication(s)
and interventions? Was the patient included in the medical decision making
and in agreement with the final plan
O NPs should not be prescribing non-FDA approved medications or medications
related to off-label use. If a physician prescribed a non-FDA-approved
medication for working diagnosis or recommended off-label use was
education provided and was the risk to benefit of the medication(s) addressed
in the patient’s education?
Prognosis Good, Fair, or Poor?
O Indicate the patient’s prognosis: Good, Fair, Poor
O Provide support for your selected prognosis
Referral/Follow-up
O Did you recommend follow-up with PCP, or other healthcare professionals?
O When is the subsequent follow-up?
Disposition:
O Indicate the disposition of the patient.
O
O
Was the patient sent home, Emergency room via EMS, etc.
Include rationale for the follow-up recommendation or referral
Reference(s)
o Include APA formatted references for written assignments.
o Minimum 2 references are required from evidence-based resources.
o Oral assignments should include verbally articulated evidence-based
guideline(s) used to prepare the oral presentation.
APPENDIX A
PREVENTATIVE CARE SCHEDULE (Example – not all-inclusive)
Preventive
Care
Pap
Mammogram
A1C
Eye Exam
Monofilament
Test
Urine
Microalbumin
Diet/Lifestyle
Modifications
Digital Rectal
Exam (DRE)
PSA
Colonoscopy
or FOBT
Dexa Scan
CXR
BNP
ECG
Echo
Stress
Test
Vaccines
Date
Result
Referrals Made
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