Tag: Model Answer

  • [Solved] Nursing Need 1 to 1 collaborative help on nursing writing assignment

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  • [Solved] Assessments

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  • [Solved] tutor

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  • [Solved] two types of leases,

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    Compare two types of leases, and describe the advantages and disadvantages of each. Which type of lease would produce the lowest risk?

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    Compare two types of leases, and describe the advantages and disadvantages of each. Which type of lease would produce the lowest risk?

  • [Solved] Journal

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    This journal entry is designed as an activity in which you take a single topic and share your personal reflections on the subject. One of the biggest challenges for new managers is leading on the first day. Managers need to be able to project an aura of confidence that will encourage others to follo…

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    Assignment Prompt & Instructions

    This journal entry is designed as an activity in which you take a single topic and share your personal reflections on the subject.
    One of the biggest challenges for new managers is leading on the first day. Managers need to be able to project an aura of confidence that will encourage others to follow them. This journal entry should come from your own experience, either as a new manager or as part of a department with a new leader. If you do not have personal experiences in these areas, project yourself into the situation to determine ways that a new leader might overcome feelings of self-doubt.
    For this assignment, you should also draw upon the module resources to support your reflections.
    **Specifically, the following critical elements must be addressed:**
    – Discuss the **challenges** that you believe people have when becoming managers, citing examples from the course readings
    – Describe your **personal experiences** either as a new manager or as part of a department with a new leader
    – Provide information on the impact of **systems theory** on effective communications for a new leader which ties into the rest of the entry
    ## What to Submit
    Submit assignment as a Word document with double spacing, 12-point Times New Roman font, and one-inch margins. Your assignment should be 400 words in length with sources cited in APA format.

  • [Solved] Firm

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    In your firm, what benefits does leasing offer compared to the purchase of an asset? Provide examples.

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    In your firm, what benefits does leasing offer compared to the purchase of an asset? Provide examples.

  • [Solved] soap 2

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    – ## SOAPNoteTemplate-1-14.docx – ## SOAPNoteRubric-1.pdf – soapnote2.png **## SOAPNoteTemplate-1-14.docx** | | | | — | — | | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance | | _Demographics_ | | | _Chief Complaint (Reason for seeking health care)_ | | | _History of Present Illness (H…

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    – ## SOAPNoteTemplate-1-14.docx

    – ## SOAPNoteRubric-1.pdf

    – soapnote2.png

    **## SOAPNoteTemplate-1-14.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **## SOAPNoteRubric-1.pdf**

    SOAP Note Rubric

    Criteria Ratings Point
    s

    Demographics 1 to >0.8 pts
    Begins with patient
    initials, age, race,
    ethnicity and
    gender (5
    demographics)

    0.8 to >0.25 pts
    Begins with 4 of
    the 5 patient
    demographics
    (patient initials,
    age, race,
    ethnicity and
    gender)

    0.25 to
    >0.0 pts
    Begins with 3
    or less patient
    demographics
    (patient
    initials, age,
    race, ethnicity
    and gender)

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    1
    point

    Chief
    Complaint
    (Reason for
    seeking health
    care)

    4 to >3.0 pts
    Includes a direct
    quote from patient
    about presenting
    problem

    3 to >2.0 pts
    Includes a direct
    quote from
    patient and
    other unrelated
    information

    2 to >0.0 pts
    Includes
    information
    but
    information is
    NOT a direct
    quote

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    4
    points

    History of the
    Present
    Illness (HPI)

    5 to >3.0 pts
    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 to >2.0 pts
    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 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Allergies 2 to >1.5 pts
    Includes 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 pts
    If 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 pts
    If allergies are
    present,
    students lists
    only the type
    of allergy
    name

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Review of
    Systems
    (ROS)

    15 to >8.0 pts
    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”

    8 to >3.0 pts
    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 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    15
    points

    Vital Signs 2 to >1.5 pts
    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 to >1.0 pts
    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 to >0.0 pts
    Includes 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 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Labs 2 to >1.5 pts
    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.

    1.5 to >1.0 pts
    Includes a list of
    the labs
    reviewed at the
    visit, values of
    lab results but
    does not
    highlight
    abnormal
    values.

    1 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Medications 4 to >2.0 pts
    Includes a list of all
    of the patient
    reported
    medications and
    the medical
    diagnosis for the
    medication
    (including name,

    2 to >1.0 pts
    Includes a list of
    all of the patient
    reported
    medications and
    the medical
    diagnosis for
    the medication
    (including 3 of

    1 to >0.0 pts
    Includes a list
    of all of the
    patient
    reported
    medications
    (including 2 of
    the 4: name,

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    4
    points

    dose, route,
    frequency)

    the 4: name,
    dose,
    medications
    route,
    frequency)

    dose, route,
    frequency)

    Past Medical
    History

    3 to >2.0 pts
    Includes
    (Major/Chronic,
    Trauma,
    Hospitalizations),
    for each medical
    diagnosis, year of
    diagnosis and
    whether the
    diagnosis is active
    or current

    2 to >1.0 pts
    Includes
    (Major/Chronic,
    Trauma,
    Hospitalizations)
    , for each
    medical
    diagnosis, either
    year of
    diagnosis OR
    whether the
    diagnosis is
    active or current

    1 to >0.0 pts
    Includes each
    medical
    diagnosis but
    does not
    include year of
    diagnosis or
    whether the
    diagnosis is
    active or
    current

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Past Surgical
    History

    3 to >2.0 pts
    Includes, for each
    surgical procedure,
    the year of
    procedure and the
    indication for the
    procedure

    2 to >1.0 pts
    Includes, for
    each surgical
    procedure, the
    year of
    procedure OR
    indication of the
    procedure

    1 to >0.0 pts
    Includes, for
    each surgical
    procedure but
    not the year of
    procedure or
    indication of
    the procedure

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Family History 3 to >2.0 pts
    Includes an
    assessment of at
    least 4 family
    members
    regarding, at a
    minimum, genetic
    disorders, diabetes,
    heart disease and
    cancer.

    2 to >1.0 pts
    Includes an
    assessment of
    at least 3 family
    members
    regarding, at a
    minimum,
    genetic
    disorders,
    diabetes, heart
    disease and
    cancer.

    1 to >0.0 pts
    Includes an
    assessment of
    at least 2
    family
    members
    regarding, at a
    minimum,
    genetic
    disorders,
    diabetes, heart
    disease and
    cancer.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Social History 3 to >2.0 pts
    Includes 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 pts
    Includes 10 of
    the 11 required
    following:
    tobacco use,
    drug use,
    alcohol use,
    marital status,
    employment
    status,
    current/previous
    occupation,
    sexual
    orientation,
    sexually active,
    contraceptive

    1 to >0.0 pts
    Includes 9 or
    less of the
    required
    information.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    use, and living
    situation.

    Health
    Maintenance /
    Screenings

    3 to >2.0 pts
    Includes 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 pts
    Includes 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 pts
    Includes
    minimal
    assessment of
    immunization
    status and
    health
    maintenance
    needs, lacking
    detail.
    Includes an
    assessment of
    at least 3
    screening
    tests

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Physical
    Examination

    15 to >8.0 pts
    Includes a
    minimum of 4
    assessments for
    each body system
    and assesses at
    least 5 body
    systems directed to
    chief complaint

    8 to >3.0 pts
    Includes a
    minimum of 3
    assessments for
    each body
    system and
    assesses at
    least 4 body
    systems
    directed to chief
    complaint

    3 to >0.0 pts
    Includes a
    minimum of 2
    assessments
    for each body
    system and
    assesses at
    least 4 body
    systems
    directed to
    chief
    complaint

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    15
    points

    Diagnosis

    5 to >3.0 pts
    Includes a clear
    outline of the
    accurate principal
    diagnosis AND lists
    the remaining
    diagnoses
    addressed at the
    visit (in descending
    priority)

    3 to >1.0 pts
    Includes 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 pts
    Includes 1
    differential
    diagnosis for
    the principal
    diagnosis

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Differential
    Diagnosis

    5 to >3.0 pts
    Includes at least 3
    differential
    diagnoses for the
    principal diagnosis

    3 to >1.0 pts
    Includes at least
    2 differential
    diagnoses for
    the principal
    diagnosis

    1 to >0.0 pts
    Includes at
    least 1
    differential
    diagnoses for
    the principal
    diagnosis

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    ICD 10 Coding 3 to >2.0 pts
    Correctly includes
    all ICD-10 codes
    relevant to the
    diagnoses
    addressed at the
    visit

    2 to >1.0 pts
    Correctly
    includes most
    ICD-10 codes
    relevant to the
    diagnoses
    addressed at the
    visit

    1 to >0.0 pts
    Includes some
    ICD-10 codes
    relevant to the
    diagnoses
    addressed at
    the visit

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Pharmacologi
    c treatment
    plan

    5 to >3.0 pts
    Includes 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 pts
    Includes 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 pts
    Includes a
    detailed
    pharmacologi
    c treatment
    plan for each
    of the
    diagnoses
    listed under
    “assessment”.
    The plan
    includes less
    than 4 of the
    information:

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Diagnostic /
    Lab Testing

    3 to >2.0 pts
    Includes
    appropriate
    diagnostic/lab
    testing 100% of the
    time OR
    acknowledges “no
    diagnostic testing
    clinically required
    at this time”

    2 to >1.0 pts
    Includes
    appropriate
    diagnostic/lab
    testing 50% of
    the time OR
    acknowledges
    “no diagnostic
    testing clinically
    required at this
    time”

    1 to >0.0 pts
    Includes
    appropriate
    diagnostic
    testing less
    than 50% of
    the time.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Education 3 to >2.0 pts
    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.

    2 to >1.0 pts
    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.

    1 to >0.0 pts
    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

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    healthy
    behaviors into
    their lives

    Anticipatory
    Guidance

    3 to >2.0 pts
    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 to >1.0 pts
    Includes 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 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Follow Up
    Plan

    2 to >1.0 pts
    Includes
    recommendation
    for follow up,
    including time
    frame (i.e. x # of
    days/weeks/months
    )

    1 to >0.0 pts
    Includes recommendation for
    follow up, but does not include
    time frame (i.e. x # of
    days/weeks/months)

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Prescription 3 to >2.0 pts
    Prescription
    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 pts
    Prescription
    includes most
    required
    components,
    but is missing 1-
    2 elements such
    as quantity to be
    dispensed or
    refills

    1 to >0.0 pts
    Prescription is
    missing 3 or
    more required
    components
    such as
    patient
    information,
    date, or
    provider’s
    signature

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Writing
    Mechanics,
    Citations, and
    APA Style

    3 to >2.0 pts
    Effectively uses the
    literature and other
    resources to inform
    their work.
    Exceptional use of
    citations and
    extended
    referencing. APA

    2 to >1.0 pts
    Moderately use
    the literature
    and other
    resources to
    inform their
    work.
    Moderately use
    of citations and

    1 to >0.0 pts
    Ineffectively
    uses the
    literature and
    other
    resources to
    inform their
    work.
    Ineffectively

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    style is correct, and
    writing is free of
    grammar and
    spelling errors.

    extended
    referencing. APA
    style and writing
    mechanics need
    more precision
    and attention to
    detail.

    use of
    citations and
    extended
    referencing.
    APA style and
    writing
    mechanics
    need serious
    attention.

    Total 100

    **soapnote2.png**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnote2-png-10449099)

    **soapnote2.png**

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    **## SOAPNoteTemplate-1-14.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **## SOAPNoteRubric-1.pdf**

    SOAP Note Rubric

    Criteria Ratings Point
    s

    Demographics 1 to >0.8 pts
    Begins with patient
    initials, age, race,
    ethnicity and
    gender (5
    demographics)

    0.8 to >0.25 pts
    Begins with 4 of
    the 5 patient
    demographics
    (patient initials,
    age, race,
    ethnicity and
    gender)

    0.25 to
    >0.0 pts
    Begins with 3
    or less patient
    demographics
    (patient
    initials, age,
    race, ethnicity
    and gender)

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    1
    point

    Chief
    Complaint
    (Reason for
    seeking health
    care)

    4 to >3.0 pts
    Includes a direct
    quote from patient
    about presenting
    problem

    3 to >2.0 pts
    Includes a direct
    quote from
    patient and
    other unrelated
    information

    2 to >0.0 pts
    Includes
    information
    but
    information is
    NOT a direct
    quote

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    4
    points

    History of the
    Present
    Illness (HPI)

    5 to >3.0 pts
    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 to >2.0 pts
    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 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Allergies 2 to >1.5 pts
    Includes 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 pts
    If 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 pts
    If allergies are
    present,
    students lists
    only the type
    of allergy
    name

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Review of
    Systems
    (ROS)

    15 to >8.0 pts
    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”

    8 to >3.0 pts
    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 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    15
    points

    Vital Signs 2 to >1.5 pts
    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 to >1.0 pts
    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 to >0.0 pts
    Includes 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 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Labs 2 to >1.5 pts
    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.

    1.5 to >1.0 pts
    Includes a list of
    the labs
    reviewed at the
    visit, values of
    lab results but
    does not
    highlight
    abnormal
    values.

    1 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Medications 4 to >2.0 pts
    Includes a list of all
    of the patient
    reported
    medications and
    the medical
    diagnosis for the
    medication
    (including name,

    2 to >1.0 pts
    Includes a list of
    all of the patient
    reported
    medications and
    the medical
    diagnosis for
    the medication
    (including 3 of

    1 to >0.0 pts
    Includes a list
    of all of the
    patient
    reported
    medications
    (including 2 of
    the 4: name,

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    4
    points

    dose, route,
    frequency)

    the 4: name,
    dose,
    medications
    route,
    frequency)

    dose, route,
    frequency)

    Past Medical
    History

    3 to >2.0 pts
    Includes
    (Major/Chronic,
    Trauma,
    Hospitalizations),
    for each medical
    diagnosis, year of
    diagnosis and
    whether the
    diagnosis is active
    or current

    2 to >1.0 pts
    Includes
    (Major/Chronic,
    Trauma,
    Hospitalizations)
    , for each
    medical
    diagnosis, either
    year of
    diagnosis OR
    whether the
    diagnosis is
    active or current

    1 to >0.0 pts
    Includes each
    medical
    diagnosis but
    does not
    include year of
    diagnosis or
    whether the
    diagnosis is
    active or
    current

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Past Surgical
    History

    3 to >2.0 pts
    Includes, for each
    surgical procedure,
    the year of
    procedure and the
    indication for the
    procedure

    2 to >1.0 pts
    Includes, for
    each surgical
    procedure, the
    year of
    procedure OR
    indication of the
    procedure

    1 to >0.0 pts
    Includes, for
    each surgical
    procedure but
    not the year of
    procedure or
    indication of
    the procedure

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Family History 3 to >2.0 pts
    Includes an
    assessment of at
    least 4 family
    members
    regarding, at a
    minimum, genetic
    disorders, diabetes,
    heart disease and
    cancer.

    2 to >1.0 pts
    Includes an
    assessment of
    at least 3 family
    members
    regarding, at a
    minimum,
    genetic
    disorders,
    diabetes, heart
    disease and
    cancer.

    1 to >0.0 pts
    Includes an
    assessment of
    at least 2
    family
    members
    regarding, at a
    minimum,
    genetic
    disorders,
    diabetes, heart
    disease and
    cancer.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Social History 3 to >2.0 pts
    Includes 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 pts
    Includes 10 of
    the 11 required
    following:
    tobacco use,
    drug use,
    alcohol use,
    marital status,
    employment
    status,
    current/previous
    occupation,
    sexual
    orientation,
    sexually active,
    contraceptive

    1 to >0.0 pts
    Includes 9 or
    less of the
    required
    information.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    use, and living
    situation.

    Health
    Maintenance /
    Screenings

    3 to >2.0 pts
    Includes 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 pts
    Includes 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 pts
    Includes
    minimal
    assessment of
    immunization
    status and
    health
    maintenance
    needs, lacking
    detail.
    Includes an
    assessment of
    at least 3
    screening
    tests

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Physical
    Examination

    15 to >8.0 pts
    Includes a
    minimum of 4
    assessments for
    each body system
    and assesses at
    least 5 body
    systems directed to
    chief complaint

    8 to >3.0 pts
    Includes a
    minimum of 3
    assessments for
    each body
    system and
    assesses at
    least 4 body
    systems
    directed to chief
    complaint

    3 to >0.0 pts
    Includes a
    minimum of 2
    assessments
    for each body
    system and
    assesses at
    least 4 body
    systems
    directed to
    chief
    complaint

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    15
    points

    Diagnosis

    5 to >3.0 pts
    Includes a clear
    outline of the
    accurate principal
    diagnosis AND lists
    the remaining
    diagnoses
    addressed at the
    visit (in descending
    priority)

    3 to >1.0 pts
    Includes 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 pts
    Includes 1
    differential
    diagnosis for
    the principal
    diagnosis

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Differential
    Diagnosis

    5 to >3.0 pts
    Includes at least 3
    differential
    diagnoses for the
    principal diagnosis

    3 to >1.0 pts
    Includes at least
    2 differential
    diagnoses for
    the principal
    diagnosis

    1 to >0.0 pts
    Includes at
    least 1
    differential
    diagnoses for
    the principal
    diagnosis

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    ICD 10 Coding 3 to >2.0 pts
    Correctly includes
    all ICD-10 codes
    relevant to the
    diagnoses
    addressed at the
    visit

    2 to >1.0 pts
    Correctly
    includes most
    ICD-10 codes
    relevant to the
    diagnoses
    addressed at the
    visit

    1 to >0.0 pts
    Includes some
    ICD-10 codes
    relevant to the
    diagnoses
    addressed at
    the visit

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Pharmacologi
    c treatment
    plan

    5 to >3.0 pts
    Includes 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 pts
    Includes 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 pts
    Includes a
    detailed
    pharmacologi
    c treatment
    plan for each
    of the
    diagnoses
    listed under
    “assessment”.
    The plan
    includes less
    than 4 of the
    information:

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Diagnostic /
    Lab Testing

    3 to >2.0 pts
    Includes
    appropriate
    diagnostic/lab
    testing 100% of the
    time OR
    acknowledges “no
    diagnostic testing
    clinically required
    at this time”

    2 to >1.0 pts
    Includes
    appropriate
    diagnostic/lab
    testing 50% of
    the time OR
    acknowledges
    “no diagnostic
    testing clinically
    required at this
    time”

    1 to >0.0 pts
    Includes
    appropriate
    diagnostic
    testing less
    than 50% of
    the time.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Education 3 to >2.0 pts
    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.

    2 to >1.0 pts
    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.

    1 to >0.0 pts
    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

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    healthy
    behaviors into
    their lives

    Anticipatory
    Guidance

    3 to >2.0 pts
    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 to >1.0 pts
    Includes 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 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Follow Up
    Plan

    2 to >1.0 pts
    Includes
    recommendation
    for follow up,
    including time
    frame (i.e. x # of
    days/weeks/months
    )

    1 to >0.0 pts
    Includes recommendation for
    follow up, but does not include
    time frame (i.e. x # of
    days/weeks/months)

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Prescription 3 to >2.0 pts
    Prescription
    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 pts
    Prescription
    includes most
    required
    components,
    but is missing 1-
    2 elements such
    as quantity to be
    dispensed or
    refills

    1 to >0.0 pts
    Prescription is
    missing 3 or
    more required
    components
    such as
    patient
    information,
    date, or
    provider’s
    signature

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Writing
    Mechanics,
    Citations, and
    APA Style

    3 to >2.0 pts
    Effectively uses the
    literature and other
    resources to inform
    their work.
    Exceptional use of
    citations and
    extended
    referencing. APA

    2 to >1.0 pts
    Moderately use
    the literature
    and other
    resources to
    inform their
    work.
    Moderately use
    of citations and

    1 to >0.0 pts
    Ineffectively
    uses the
    literature and
    other
    resources to
    inform their
    work.
    Ineffectively

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    style is correct, and
    writing is free of
    grammar and
    spelling errors.

    extended
    referencing. APA
    style and writing
    mechanics need
    more precision
    and attention to
    detail.

    use of
    citations and
    extended
    referencing.
    APA style and
    writing
    mechanics
    need serious
    attention.

    Total 100

    **soapnote2.png**

    This file is too large to display. [View in new window](https://www.sweetstudy.com/files/soapnote2-png-10449099)

    **## SOAPNoteTemplate-1-14.docx**

    | | |
    | — | — |
    | SOAP NOTE TEMPLATE<br>Review the Rubric for more Guidance |
    | _Demographics_ | |
    | _Chief Complaint (Reason for seeking health care)_ | |
    | _History of Present Illness (HPI)_ | |
    | _Allergies_ | |
    | _Review of Systems (ROS)_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: <br>Nutrition:<br>Sleep/Rest:<br>LMP: <br>STI Hx: |
    | _Vital Signs_ | |
    | _Labs_ | |
    | _Medications_ | |
    | _Past Medical History_ | |
    | _Past Surgical History_ | |
    | _Family History_ | |
    | _Social History_ | |
    | _Health Maintenance/ Screenings_ | |
    | _Physical Examination_ | General: <br>HEENT:<br>Neck: <br>Lungs:<br>Cardio<br>Breast: <br>GI: <br>M/F genital:<br>GU: <br>Neuro<br>Musculo:<br>Activity:<br>Psychosocial: <br>Derm: |
    | _Diagnosis_ | |
    | _Differential Diagnosis_ | |
    | _ICD 10 Coding_ | |
    | _Pharmacologic treatment plan_ | |
    | _Diagnostic/Lab Testing_ | |
    | _Education_ | |
    | _Anticipatory Guidance_ | |
    | _Follow up plan_ | |
    | _Prescription_ | See Below (scroll down) |
    | _References_ | |
    | _Grammar_ | |

    | |
    | — |
    | EA#: 101010101 STU Clinic LIC# 10000000 |
    | Tel: (000) 555-1234 FAX: (000) 555-12222 |
    | Patient Name: (Initials)______________________________ Age ___________<br>Date: _______________<br>RX ______________________________________<br>SIG:<br>Dispense: ___________ Refill: _________________<br>No Substitution<br> <br>Signature:____________________________________________________________ |

    Signature (with appropriate credentials):_____________________________________

    References (must use current evidence-based guidelines used to guide the care [Mandatory])

    **## SOAPNoteRubric-1.pdf**

    SOAP Note Rubric

    Criteria Ratings Point
    s

    Demographics 1 to >0.8 pts
    Begins with patient
    initials, age, race,
    ethnicity and
    gender (5
    demographics)

    0.8 to >0.25 pts
    Begins with 4 of
    the 5 patient
    demographics
    (patient initials,
    age, race,
    ethnicity and
    gender)

    0.25 to
    >0.0 pts
    Begins with 3
    or less patient
    demographics
    (patient
    initials, age,
    race, ethnicity
    and gender)

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    1
    point

    Chief
    Complaint
    (Reason for
    seeking health
    care)

    4 to >3.0 pts
    Includes a direct
    quote from patient
    about presenting
    problem

    3 to >2.0 pts
    Includes a direct
    quote from
    patient and
    other unrelated
    information

    2 to >0.0 pts
    Includes
    information
    but
    information is
    NOT a direct
    quote

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    4
    points

    History of the
    Present
    Illness (HPI)

    5 to >3.0 pts
    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 to >2.0 pts
    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 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Allergies 2 to >1.5 pts
    Includes 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 pts
    If 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 pts
    If allergies are
    present,
    students lists
    only the type
    of allergy
    name

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Review of
    Systems
    (ROS)

    15 to >8.0 pts
    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”

    8 to >3.0 pts
    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 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    15
    points

    Vital Signs 2 to >1.5 pts
    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 to >1.0 pts
    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 to >0.0 pts
    Includes 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 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Labs 2 to >1.5 pts
    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.

    1.5 to >1.0 pts
    Includes a list of
    the labs
    reviewed at the
    visit, values of
    lab results but
    does not
    highlight
    abnormal
    values.

    1 to >0.0 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Medications 4 to >2.0 pts
    Includes a list of all
    of the patient
    reported
    medications and
    the medical
    diagnosis for the
    medication
    (including name,

    2 to >1.0 pts
    Includes a list of
    all of the patient
    reported
    medications and
    the medical
    diagnosis for
    the medication
    (including 3 of

    1 to >0.0 pts
    Includes a list
    of all of the
    patient
    reported
    medications
    (including 2 of
    the 4: name,

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    4
    points

    dose, route,
    frequency)

    the 4: name,
    dose,
    medications
    route,
    frequency)

    dose, route,
    frequency)

    Past Medical
    History

    3 to >2.0 pts
    Includes
    (Major/Chronic,
    Trauma,
    Hospitalizations),
    for each medical
    diagnosis, year of
    diagnosis and
    whether the
    diagnosis is active
    or current

    2 to >1.0 pts
    Includes
    (Major/Chronic,
    Trauma,
    Hospitalizations)
    , for each
    medical
    diagnosis, either
    year of
    diagnosis OR
    whether the
    diagnosis is
    active or current

    1 to >0.0 pts
    Includes each
    medical
    diagnosis but
    does not
    include year of
    diagnosis or
    whether the
    diagnosis is
    active or
    current

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Past Surgical
    History

    3 to >2.0 pts
    Includes, for each
    surgical procedure,
    the year of
    procedure and the
    indication for the
    procedure

    2 to >1.0 pts
    Includes, for
    each surgical
    procedure, the
    year of
    procedure OR
    indication of the
    procedure

    1 to >0.0 pts
    Includes, for
    each surgical
    procedure but
    not the year of
    procedure or
    indication of
    the procedure

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Family History 3 to >2.0 pts
    Includes an
    assessment of at
    least 4 family
    members
    regarding, at a
    minimum, genetic
    disorders, diabetes,
    heart disease and
    cancer.

    2 to >1.0 pts
    Includes an
    assessment of
    at least 3 family
    members
    regarding, at a
    minimum,
    genetic
    disorders,
    diabetes, heart
    disease and
    cancer.

    1 to >0.0 pts
    Includes an
    assessment of
    at least 2
    family
    members
    regarding, at a
    minimum,
    genetic
    disorders,
    diabetes, heart
    disease and
    cancer.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Social History 3 to >2.0 pts
    Includes 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 pts
    Includes 10 of
    the 11 required
    following:
    tobacco use,
    drug use,
    alcohol use,
    marital status,
    employment
    status,
    current/previous
    occupation,
    sexual
    orientation,
    sexually active,
    contraceptive

    1 to >0.0 pts
    Includes 9 or
    less of the
    required
    information.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    use, and living
    situation.

    Health
    Maintenance /
    Screenings

    3 to >2.0 pts
    Includes 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 pts
    Includes 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 pts
    Includes
    minimal
    assessment of
    immunization
    status and
    health
    maintenance
    needs, lacking
    detail.
    Includes an
    assessment of
    at least 3
    screening
    tests

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Physical
    Examination

    15 to >8.0 pts
    Includes a
    minimum of 4
    assessments for
    each body system
    and assesses at
    least 5 body
    systems directed to
    chief complaint

    8 to >3.0 pts
    Includes a
    minimum of 3
    assessments for
    each body
    system and
    assesses at
    least 4 body
    systems
    directed to chief
    complaint

    3 to >0.0 pts
    Includes a
    minimum of 2
    assessments
    for each body
    system and
    assesses at
    least 4 body
    systems
    directed to
    chief
    complaint

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    15
    points

    Diagnosis

    5 to >3.0 pts
    Includes a clear
    outline of the
    accurate principal
    diagnosis AND lists
    the remaining
    diagnoses
    addressed at the
    visit (in descending
    priority)

    3 to >1.0 pts
    Includes 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 pts
    Includes 1
    differential
    diagnosis for
    the principal
    diagnosis

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Differential
    Diagnosis

    5 to >3.0 pts
    Includes at least 3
    differential
    diagnoses for the
    principal diagnosis

    3 to >1.0 pts
    Includes at least
    2 differential
    diagnoses for
    the principal
    diagnosis

    1 to >0.0 pts
    Includes at
    least 1
    differential
    diagnoses for
    the principal
    diagnosis

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    ICD 10 Coding 3 to >2.0 pts
    Correctly includes
    all ICD-10 codes
    relevant to the
    diagnoses
    addressed at the
    visit

    2 to >1.0 pts
    Correctly
    includes most
    ICD-10 codes
    relevant to the
    diagnoses
    addressed at the
    visit

    1 to >0.0 pts
    Includes some
    ICD-10 codes
    relevant to the
    diagnoses
    addressed at
    the visit

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Pharmacologi
    c treatment
    plan

    5 to >3.0 pts
    Includes 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 pts
    Includes 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 pts
    Includes a
    detailed
    pharmacologi
    c treatment
    plan for each
    of the
    diagnoses
    listed under
    “assessment”.
    The plan
    includes less
    than 4 of the
    information:

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    5
    points

    Diagnostic /
    Lab Testing

    3 to >2.0 pts
    Includes
    appropriate
    diagnostic/lab
    testing 100% of the
    time OR
    acknowledges “no
    diagnostic testing
    clinically required
    at this time”

    2 to >1.0 pts
    Includes
    appropriate
    diagnostic/lab
    testing 50% of
    the time OR
    acknowledges
    “no diagnostic
    testing clinically
    required at this
    time”

    1 to >0.0 pts
    Includes
    appropriate
    diagnostic
    testing less
    than 50% of
    the time.

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Education 3 to >2.0 pts
    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.

    2 to >1.0 pts
    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.

    1 to >0.0 pts
    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

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    healthy
    behaviors into
    their lives

    Anticipatory
    Guidance

    3 to >2.0 pts
    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 to >1.0 pts
    Includes 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 pts
    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
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Follow Up
    Plan

    2 to >1.0 pts
    Includes
    recommendation
    for follow up,
    including time
    frame (i.e. x # of
    days/weeks/months
    )

    1 to >0.0 pts
    Includes recommendation for
    follow up, but does not include
    time frame (i.e. x # of
    days/weeks/months)

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    2
    points

    Prescription 3 to >2.0 pts
    Prescription
    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 pts
    Prescription
    includes most
    required
    components,
    but is missing 1-
    2 elements such
    as quantity to be
    dispensed or
    refills

    1 to >0.0 pts
    Prescription is
    missing 3 or
    more required
    components
    such as
    patient
    information,
    date, or
    provider’s
    signature

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    Writing
    Mechanics,
    Citations, and
    APA Style

    3 to >2.0 pts
    Effectively uses the
    literature and other
    resources to inform
    their work.
    Exceptional use of
    citations and
    extended
    referencing. APA

    2 to >1.0 pts
    Moderately use
    the literature
    and other
    resources to
    inform their
    work.
    Moderately use
    of citations and

    1 to >0.0 pts
    Ineffectively
    uses the
    literature and
    other
    resources to
    inform their
    work.
    Ineffectively

    0 pts
    Missing
    criteria
    and/or
    submission
    .

    3
    points

    style is correct, and
    writing is free of
    grammar and
    spelling errors.

    extended
    referencing. APA
    style and writing
    mechanics need
    more precision
    and attention to
    detail.

    use of
    citations and
    extended
    referencing.
    APA style and
    writing
    mechanics
    need serious
    attention.

    Total 100

    **soapnote2.png**

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    – 1
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    – ## ComprehensiveQuiz.docx

    **## ComprehensiveQuiz.docx**

    **Answer only one of the following questions thoroughly. Your answer should be a minimum of two full pages. Credit will be awarded for attention to detail, writing in your own words and use of personal examples, eloquent expression of thoughts, views, opinions, feelings, clarity of expression, evidence of creativity and critical thinking, and citing of sources. You must cite the sources of all your information including the course textbook and the sources of any Artificial Intelligence (AI)-generated information in the narrative and at the end of the narrative of the question you select to answer. Rubrics/guidelines for answering the question you select are provided below. Also check the course syllabus for more information on rubrics for writing essay assignments.**

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    **Evidence of creativity and critical thinking and citing of sources            —–Up to 10 points**

    **## ComprehensiveQuiz.docx**

    **Answer only one of the following questions thoroughly. Your answer should be a minimum of two full pages. Credit will be awarded for attention to detail, writing in your own words and use of personal examples, eloquent expression of thoughts, views, opinions, feelings, clarity of expression, evidence of creativity and critical thinking, and citing of sources. You must cite the sources of all your information including the course textbook and the sources of any Artificial Intelligence (AI)-generated information in the narrative and at the end of the narrative of the question you select to answer. Rubrics/guidelines for answering the question you select are provided below. Also check the course syllabus for more information on rubrics for writing essay assignments.**

    **1. Using detailed examples, discuss three lessons you have learned from this course about the historical development of education, laws regarding education, philosophies relevant to education (such as idealism, realism, pragmatism, existentialism, Native North American and Eastern ways of knowing), students and their families, diversity in society, and the roles of schools in society.**

    **2. Using detailed examples, discuss three strategies you would utilize to apply what you have learned in this course in relation to the historical development of education, laws regarding education, philosophies relevant to education (such as idealism, realism, pragmatism, existentialism, Native North American and Eastern ways of knowing), students and their families, diversity in society, and the roles of schools in society.**

    **Rubrics/Guidelines for answering the question you select:**

    **Statement of points       ——————Up to 10 Points**

    **Detailed discussion of points including an introduction, a conclusion, use of arguments, use of examples, use of explanations, eloquent expression of thoughts, feelings, views, and opinions, and suggestions for addressing challenges or problems.    ———Up to 80 points**

    **Evidence of creativity and critical thinking and citing of sources            —–Up to 10 points**