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SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
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.
SOAP Note TemplateDownload SOAP Note Template
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 misspelling.
Attention: Complete and submit the assignment using the appropriate template in MS Word by 11:59 PM ET Friday.
Grading Rubric
Your assignment will be graded according to the grading rubric.
STU FNP SOAP Note Rubric.pdfDownload STU FNP SOAP Note Rubric.pdf
View Rubric
SOAP Notes Rubric
SOAP Notes Rubric
CriteriaRatingsPts
Chief Complaint (Reason for seeking health care) – S4 pts
Distinguished
Includes a direct quote from patient about presenting problem3 pts
Excellent
Includes a direct quote from patient and other unrelated information2 pts
Fair
Includes information but information is NOT a direct quote0 pts
Poor
Information is completely missing/ 4 pts
Demographics – S
2 pts
Distinguished
Begins with patient initials, age, race, ethnicity and gender (5 demographics)1.5 pts
Excellent
Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)1 pts
Fair
Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)0 pts
Poor
Information is completely missing/ 2 pts
History of the Present Illness (HPI) – S
5 pts
Distinguished
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 pts
Excellent
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 pts
Fair
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
Poor
Information is completely missing/ 5 pts
Allergies – S
2 pts
Distinguished
Includes NKA (including = Drug, Environemental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)1.5 pts
Excellent
If allergies are present, students lists type Drug, environemtal factor, herbal, food, latex name and includes severity of allergy OR description of allergy1 pts
Fair
If allergies are present, students lists only the type of allergy name0 pts
Poor
Information is completely missing/ 2 pts
Review of Systems (ROS) – S
12 pts
Distinguished
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”6 pts
Excellent
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 pts
Fair
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
Poor
Information is completely missing/ 12 pts
Vital Signs – O
2 pts
Distinguished
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 pts
Excellent
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 pts
Fair
Includes 6 or less 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.)0 pts
Poor
Information is completely missing/ 2 pts
Labs – O
3 pts
Distinguished
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.2 pts
Excellent
Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.1 pts
Fair
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
Poor
Information is completely missing/ 3 pts
Medications – O
4 pts
Distinguished
Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)2 pts
Excellent
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 pts
Fair
Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)0 pts
Poor
Information is completely missing/ 4 pts
Screenings – O
3 pts
Distinguished
Includes an assessment of at least 5 screening tests2 pts
Excellent
Includes an assessment of at least 4 screening tests1 pts
Fair
Includes an assessment of at least 3 screening tests0 pts
Poor
Information is completely missing/ 3 pts
Past Medical History – O
3 pts
Distinguished
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current2 pts
Excellent
Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current1 pts
Fair
Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current0 pts
Poor
Information is completely missing/ 3 pts
Past Surgical History – O
3 pts
Distinguished
Includes, for each surgical procedure, the year of procedure and the indication for the procedure2 pts
Excellent
Includes, for each surgical procedure, the year of procedure OR indication of the procedure1 pts
Fair
Includes, for each surgical procedure but not the year of procedure or indication of the procedure0 pts
Poor
Information is completely missing/ 3 pts
Family History – O
3 pts
Distinguished
Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.2 pts
Excellent
Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.1 pts
Fair
Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.0 pts
Poor
Information is completely missing/ 3 pts
Social History – O
3 pts
Distinguished
Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.2 pts
Excellent
Includes 10 of the 11 following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.1 pts
Fair
Includes 9 or less of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.0 pts
Poor
Information is completely missing/ 3 pts
Physical Examination – O
12 pts
Distinguished
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint6 pts
Excellent
Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint3 pts
Fair
Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint0 pts
Poor
Information is completely missing/ 12 pts
Diagnosis – A
5 pts
Distinguished
Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)3 pts
Excellent
Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority2 pts
Fair
Includes an inaccurate diagnosis as the principal diagnosis0 pts
Poor
Information is completely missing/ 5 pts
Differential Diagnosis – A
5 pts
Distinguished
Includes at least 3 differential diagnoses for the principal diagnosis3 pts
Excellent
Includes 2 differential diagnoses for the principal diagnosis2 pts
Fair
Includes 1 differential diagnosis for the principal diagnosis0 pts
Poor
Information is completely missing/ 5 pts
Pharmacologic treatment plan – P
5 pts
Distinguished
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the 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 pts
Excellent
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the 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.2 pts
Fair
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the following: 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.0 pts
Poor
Information is completely missing/ 5 pts
Diagnostic/Lab Testing – P
5 pts
Distinguished
Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”3 pts
Excellent
Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”2 pts
Fair
Includes appropriate diagnostic testing less than 50% of the time.0 pts
Poor
Information is completely missing/ 5 pts
Education – P
5 pts
Distinguished
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.3 pts
Excellent
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.2 pts
Fair
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
Poor
Information is completely missing/ 5 pts
Anticipatory Guidance – P
4 pts
Distinguished
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 pts
Excellent
Includes at least 2 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))1 pts
Fair
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
Poor
Information is completely missing/ 4 pts
Follow up plan – P
4 pts
Distinguished
Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)2 pts
Excellent
Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)0 pts
Poor
Does not include follow up plan/ 4 pts
References
3 pts
Distinguished
High level of APA precision2 pts
Excellent
Moderate level of APA precision1 pts
Fair
Incorrect APA style0 pts
Poor
Information is completely missing/ 3 pts
Grammar
3 pts
Distinguished
Free of grammar and spelling errors2 pts
Excellent
Writing mechanics need more precision and attention to detail0 pts
Poor
Writing mechanics need serious attention
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