A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
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 =Plan: Treatment, diagnostic testing, and follow up
Rubric
SOAP Note Rubric
SOAP Note Rubric
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeDemographics
1 to >0.8 ptsBegins with patient initials, age, race, ethnicity and gender (5 demographics)
0.8 to >0.25 ptsBegins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)
0.25 to >0.0 ptsBegins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)
0 ptsMissing criteria and/or submission.
1 pts
This criterion is linked to a Learning OutcomeChief Complaint (Reason for seeking health care)
4 to >3.0 ptsIncludes a direct quote from patient about presenting problem
3 to >2.0 ptsIncludes a direct quote from patient and other unrelated information
2 to >0.0 ptsIncludes information but information is NOT a direct quote
0 ptsMissing criteria and/or submission.
4 pts
This criterion is linked to a Learning OutcomeHistory of the Present Illness (HPI)
5 to >3.0 ptsIncludes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
3 to >2.0 ptsIncludes 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 to >0.0 ptsIncludes 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 ptsMissing criteria and/or submission.
5 pts
This criterion is linked to a Learning OutcomeAllergies
2 to >1.5 ptsIncludes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
1.5 to >1.0 ptsIf allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy
1 to >0.0 ptsIf allergies are present, students lists only the type of allergy name
0 ptsMissing criteria and/or submission.
2 pts
This criterion is linked to a Learning OutcomeReview of Systems (ROS)
15 to >8.0 ptsIncludes 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”
8 to >3.0 ptsIncludes 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 to >0.0 ptsIncludes 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 ptsMissing criteria and/or submission.
15 pts
This criterion is linked to a Learning OutcomeVital Signs
2 to >1.5 ptsIncludes 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 to >1.0 ptsIncludes 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 to >0.0 ptsIncludes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
0 ptsMissing criteria and/or submission.
2 pts
This criterion is linked to a Learning OutcomeLabs
2 to >1.5 ptsIncludes 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.
1.5 to >1.0 ptsIncludes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.
1 to >0.0 ptsIncludes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.
0 ptsMissing criteria and/or submission.
2 pts
This criterion is linked to a Learning OutcomeMedications
4 to >2.0 ptsIncludes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)
2 to >1.0 ptsIncludes 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 to >0.0 ptsIncludes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)
0 ptsMissing criteria and/or submission.
4 pts
This criterion is linked to a Learning OutcomePast Medical History
3 to >2.0 ptsIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
2 to >1.0 ptsIncludes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current
1 to >0.0 ptsIncludes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomePast Surgical History
3 to >2.0 ptsIncludes, for each surgical procedure, the year of procedure and the indication for the procedure
2 to >1.0 ptsIncludes, for each surgical procedure, the year of procedure OR indication of the procedure
1 to >0.0 ptsIncludes, for each surgical procedure but not the year of procedure or indication of the procedure
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomeFamily History
3 to >2.0 ptsIncludes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
2 to >1.0 ptsIncludes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
1 to >0.0 ptsIncludes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomeSocial History
3 to >2.0 ptsIncludes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
2 to >1.0 ptsIncludes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
1 to >0.0 ptsIncludes 9 or less of the required information.
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomeHealth Maintenance / Screenings
3 to >2.0 ptsIncludes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests
2 to >1.0 ptsIncludes a partial assessment of immunization status and health maintenance needs, missing some key components. Includes an assessment of at least 4 screening tests
1 to >0.0 ptsIncludes minimal assessment of immunization status and health maintenance needs, lacking detail. Includes an assessment of at least 3 screening tests
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomePhysical Examination
15 to >8.0 ptsIncludes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
8 to >3.0 ptsIncludes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint
3 to >0.0 ptsIncludes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint
0 ptsMissing criteria and/or submission.
15 pts
This criterion is linked to a Learning OutcomeDiagnosis
5 to >3.0 ptsIncludes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
3 to >1.0 ptsIncludes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority
1 to >0.0 ptsIncludes 1 differential diagnosis for the principal diagnosis
0 ptsMissing criteria and/or submission.
5 pts
This criterion is linked to a Learning OutcomeDifferential Diagnosis
5 to >3.0 ptsIncludes at least 3 differential diagnoses for the principal diagnosis
3 to >1.0 ptsIncludes at least 2 differential diagnoses for the principal diagnosis
1 to >0.0 ptsIncludes at least 1 differential diagnoses for the principal diagnosis
0 ptsMissing criteria and/or submission.
5 pts
This criterion is linked to a Learning OutcomeICD 10 Coding
3 to >2.0 ptsCorrectly includes all ICD-10 codes relevant to the diagnoses addressed at the visit
2 to >1.0 ptsCorrectly includes most ICD-10 codes relevant to the diagnoses addressed at the visit
1 to >0.0 ptsIncludes some ICD-10 codes relevant to the diagnoses addressed at the visit
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomePharmacologic treatment plan
5 to >3.0 ptsIncludes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required 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 to >1.0 ptsIncludes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the required 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.
1 to >0.0 ptsIncludes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the information:
0 ptsMissing criteria and/or submission.
5 pts
This criterion is linked to a Learning OutcomeDiagnostic / Lab Testing
3 to >2.0 ptsIncludes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
2 to >1.0 ptsIncludes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”
1 to >0.0 ptsIncludes appropriate diagnostic testing less than 50% of the time.
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomeEducation
3 to >2.0 ptsIncludes 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.
2 to >1.0 ptsIncludes 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.
1 to >0.0 ptsIncludes 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 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomeAnticipatory Guidance
3 to >2.0 ptsIncludes 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 to >1.0 ptsIncludes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipator guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))
1 to >0.0 ptsIncludes 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 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomeFollow Up Plan
2 to >1.0 ptsIncludes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)
1 to >0.0 ptsIncludes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)
0 ptsMissing criteria and/or submission.
2 pts
This criterion is linked to a Learning OutcomePrescription
3 to >2.0 ptsPrescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials
2 to >1.0 ptsPrescription includes most required components, but is missing 1-2 elements such as quantity to be dispensed or refills
1 to >0.0 ptsPrescription is missing 3 or more required components such as patient information, date, or provider’s signature
0 ptsMissing criteria and/or submission.
3 pts
This criterion is linked to a Learning OutcomeWriting Mechanics, Citations, and APA Style
3 to >2.0 ptsEffectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.
2 to >1.0 ptsModerately use the literature and other resources to inform their work. Moderately use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail.
1 to >0.0 ptsIneffectively uses the literature and other resources to inform their work. Ineffectively use of citations and extended referencing. APA style and writing mechanics need serious attention.
0 ptsMissing criteria and/or submission.
3 pts
Total Points: 100
Ru =Plan: Treatment, diagnostic testing, and follow upu