Assignment Prompt & Instructions
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. **P** =Plan: Treatment, diagnostic testing, and follow up
#### **Submission Instructions:**
– Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
– You must use the template provided. Turnitin will recognize the template and not score against it.
– Your submission will be reviewed for plagiarism through Turnitin.
SOAP Note Rubric **SOAP Note RubricCriteriaRatingsPts**
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 pts**
**Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)**
**0 pts**
**Missing criteria and/or submission.**
/ 1 pts
Chief Complaint (Reason for seeking health care)
**4 to >3 pts**
**Includes a direct quote from patient about presenting problem**
**3 to >2 pts**
**Includes a direct quote from patient and other unrelated information**
**2 to >0 pts**
**Includes information but information is NOT a direct quote**
**0 pts**
**Missing criteria and/or submission.**
/ 4 pts
History of the Present Illness (HPI)
**5 to >3 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 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 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 pts
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 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 pts**
**If allergies are present, students lists only the type of allergy name**
**0 pts**
**Missing criteria and/or submission.**
/ 2 pts
Review of Systems (ROS)
**15 to >8 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 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 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 pts
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 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 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 pts
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 pts**
**Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.**
**1 to >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 pts
Medications
**4 to >2 pts**
**Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)**
**2 to >1 pts**
**Includes 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 pts**
**Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)**
**0 pts**
**Missing criteria and/or submission.**
/ 4 pts
Past Medical History
**3 to >2 pts**
**Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current**
**2 to >1 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 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 pts
Past Surgical History
**3 to >2 pts**
**Includes, for each surgical procedure, the year of procedure and the indication for the procedure**
**2 to >1 pts**
**Includes, for each surgical procedure, the year of procedure OR indication of the procedure**
**1 to >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 pts
Family History
**3 to >2 pts**
**Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.**
**2 to >1 pts**
**Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.**
**1 to >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 pts
Social History
**3 to >2 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 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 use, and living situation.**
**1 to >0 pts**
**Includes 9 or less of the required information.**
**0 pts**
**Missing criteria and/or submission.**
/ 3 pts
Health Maintenance / Screenings
**3 to >2 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 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 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 pts
Physical Examination
**15 to >8 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 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 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 pts
Diagnosis
**5 to >3 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 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 pts**
**Includes 1 differential diagnosis for the principal diagnosis**
**0 pts**
**Missing criteria and/or submission.**
/ 5 pts
Differential Diagnosis
**5 to >3 pts**
**Includes at least 3 differential diagnoses for the principal diagnosis**
**3 to >1 pts**
**Includes at least 2 differential diagnoses for the principal diagnosis**
**1 to >0 pts**
**Includes at least 1 differential diagnoses for the principal diagnosis**
**0 pts**
**Missing criteria and/or submission.**
/ 5 pts
ICD 10 Coding
**3 to >2 pts**
**Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit**
**2 to >1 pts**
**Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit**
**1 to >0 pts**
**Includes some ICD-10 codes relevant to the diagnoses addressed at the visit**
**0 pts**
**Missing criteria and/or submission.**
/ 3 pts
Pharmacologic treatment plan
**5 to >3 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 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 pts**
**Includes a detailed pharmacologic 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 pts
Diagnostic / Lab Testing
**3 to >2 pts**
**Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”**
**2 to >1 pts**
**Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”**
**1 to >0 pts**
**Includes appropriate diagnostic testing less than 50% of the time.**
**0 pts**
**Missing criteria and/or submission.**
/ 3 pts
Education
**3 to >2 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 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 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 healthy behaviors into their lives**
**0 pts**
**Missing criteria and/or submission.**
/ 3 pts
Anticipatory Guidance
**3 to >2 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 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 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 pts
Follow Up Plan
**2 to >1 pts**
**Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)**
**1 to >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 pts
Prescription
**3 to >2 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 pts**
**Prescription includes most required components, but is missing 1-2 elements such as quantity to be dispensed or refills**
**1 to >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 pts
Writing Mechanics, Citations, and APA Style
**3 to >2 pts**
**Effectively 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 pts**
**Moderately 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 pts**
**Ineffectively 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 pts**
**Missing criteria and/or submission.**
/ 3 pts
Total Points: 0
FOLLOW RUBRIC
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SOAPNoteTemplate4.docx](https://www.sweetstudy.com/files/soapnotetemplate4-docx-10197219 "SOAPNoteTemplate4.docx")
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