February 5, 2022

Faculty Comments:? MRU Soap Note Grading Rubric This sheet is to help you understand what is required, and what the margin

Faculty Comments: MRU Soap Note Grading Rubric
This sheet is to help you understand what is required, and what the margin remarks might be about on your comments of patients. Since most of your comments that you hand in are uniform, this represents what MUST be included in every write-up.

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

Guidelines for Focused SOAP Notes

· Label each section of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbreviations

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.

History of present illness (HPI): a chronological description of the development of the patient's chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient's family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and patient's progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be "ruled out" rather state the working definitions of each differential or primary diagnosis (es).

For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.

1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.

2. Additional diagnostic tests include EBP citations to support ordering additional tests

3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.

4. Referrals include citations to support a referral

5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.

<table border="0" width="100%" cellpadding="0" cellspacing="0"> <tr> <td bgcolor="#000000" style="padding-left:2px; padding-right:10px; padding-top:2px; padding-bottom:2px">   Miami Regional University   (Acct #3111)</td> </tr> </table> <table border="0" width="100%" cellpadding="0" cellspacing="0" bgcolor="#C0C0C0"> <tr> <td width="50%">  Case ID #: 2844-20220201-005   (Status: Pending) </td> <td width="50%"> Date of Service: 2/1/2022 </td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td WIDTH="100%" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> Student Information – Santiesteban Molina, Osmel</td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> Semester:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> Spring </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> Course:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> MSN6050C Advanced Practice Women Health </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> Preceptor: </td> <td WIDTH="50%" bgcolor="#FFFFFF"> TREJO, RODOLFO </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> Clinical Site:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> Neighborhood Family Doctor.Atlantis </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> Setting Type:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> Underserved area/population </td> </tr> <tr> <td WIDTH="100%" bgcolor="#000000" align="right" colspan="2" style="border-style: solid; border-width: 2px"> Patient Demographics</td> </tr> <tr> <td bgcolor="#FFFFFF"> Age:</td> <td bgcolor="#FFFFFF"> 22 years </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF"> Race:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> Hispanic </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF"> Gender:</td> <td WIDTH="50%" bgcolor="#FFFFFF"> Female </td> </tr> <tr> <td bgcolor="#FFFFFF"> Insurance:</td> <td bgcolor="#FFFFFF"> Private insurance </td> </tr> <tr> <td bgcolor="#FFFFFF"> Referral:</td> <td bgcolor="#FFFFFF"> No referral </td> </tr> <tr> <td valign="top" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> Clinical Information</td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Time with Patient:</td> <td bgcolor="#FFFFFF"> 15 minutes</td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Consult with Preceptor:</td> <td bgcolor="#FFFFFF"> 5 minutes</td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Type of Decision-Making:</td> <td bgcolor="#FFFFFF"> Straightforward </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Reason for Visit:</td> <td bgcolor="#FFFFFF"> Follow-up (Consult) </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Chief Complaint:</td> <td bgcolor="#FFFFFF"> "I have a non painful lump in my private parts" </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> Type of HP:</td> <td bgcolor="#FFFFFF"> Problem Focused </td> </tr> <tr> <td bgcolor="#FFFFFF" align="right" valign="top"> Social Problems Addressed:</td> <td bgcolor="#FFFFFF"> Sanitation/Hygiene Safety Emotional Sexuality Nutrition/Exercise  </td> </tr> </table> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"> Procedures/Skills (Observed/Assisted/Performed)</td> </tr> <tr> <td width="100%" bgcolor="#FFFFFF" align="left" colspan="2"> General Skills – Vital Signs (Perf) </td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"> ICD-10 Diagnosis Codes</td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> #1 -  </td> <td width="90%" bgcolor="#FFFFFF" align="left"> N75.0 - CYST OF BARTHOLIN'S GLAND </td> </tr> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> CPT Billing Codes</td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> #1 -  </td> <td width="90%" bgcolor="#FFFFFF" align="left"> 99212 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 10-19 MIN </td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> Birth & Delivery</td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> Medications</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> # OTC Drugs taken regularly:</td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> 0</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> # Prescriptions currently prescribed:</td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> 0</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> # New/Refilled Prescriptions This Visit:</td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> 3</td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> Types of New/Refilled Prescriptions This Visit: Analgesic/Antipyretic – NSAIDS Dermatology – Combination anti-infectives/corticosteroid Infectious Diseases – Penicillins  </td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"> Adherence Issues with Medications:  </td> </tr> </table> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"> Other Questions About This Case</td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> Patient's Primary Language:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> Spanish </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> Smoking Assessment:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> Never </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> Advanced Directive:</td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"> No </td> </tr> <tr><td bgcolor='#FFFFFF' valign = 'top' width='50%'>Packs per day:</td><td bgcolor='#FFFFFF'>0</td></tr> </table> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td width="100%" bgcolor="#000000" align="left" valign="top" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"> Clinical Notes</td> </tr> <tr> <td width="100%" bgcolor="#FFFFFF" align="left" valign="top" colspan="2"> </td> </tr> </table>

SOAP NOTE: Post-Menopausia bleeding.

STUDENT NAME

MRU

MSN6050 ADVANCE PRACTICE IN PRIMARY CARE- WOMEN’S HEALTH.

PATIENT INFORMATION

Name: Ms. TM

Age: 57 years old

Race: Hispanic

Gender at birth: Female.

Gender identity: Female.

Source: Patient.

Allergies: Penicillin.

Current medications: Lisinopril 10 mg tab, 1tab daily.

Atorvastatin 20 mg tab, 1 tab daily.

Insurance: PPO.

PMH: Denies.

Surgical History: Appendectomy at 13 y/o.

Immunizations: Influenza. December 2020.

Preventive care: Last PAP smear August 2018. Normal.

Mammogram: Normal. BIRADS 0

Exposure: No knows HIV exposure during the last year. No blood transfusions or received other blood components or tissues.

Environmental exposure was unknown to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time.

Family History: Father deceased CAD.

Mother alive: 85 y/o, HTN.

Social History: Patient is heterosexual, single, and lives with her husband, roommate, and has a daughter 35 y/o. No domestic violence suspected or negligent behaviors. Client denies using drugs she said that she drinks alcohol only socially. Patient denies smoking tobacco or marihuana.

Nutrition history: She reports a healthy diet, low in sugar and salt.

Chief complaint: “I have my period again”

History of present illness: The patient is a Hispanic female, 57 y/o, G1T1P0A0L1, that

comes to the office staying “I have my period again”. She reports that she has watery, bloody

vaginal discharge for 2 weeks. This never happen before. Her last menstrual period was around 8

years ago. The client denied having had vaginal discharge. She is divorced for three years ago

and she did not have sexual activity since that time. The las pap test was in 2018, and the result

comeback negative. She denies history of sexual assault or trauma, also reports mild

discomfort on pelvic area, no fever or chills. There is not change on her appetite, no weight loss, malaise or weakness.

No previous hospitalizations or invasive procedures in the past twelve months. No history of

mental illness. No physical trauma or falls reported during the last year.

HPI- Women’s Health part:

Menstrual history: Monthly, denies clot or bleeding.

Age of Menarche: 11 yo

Last menstrual period: 2013.

Bleeding pattern. Reports vaginal bleeding during the last 2 weeks.

Associated pain (dysmenorrhea): N/A.

Break through bleeding: N/A.

Length of cycle: N/A.

Average number of days of menses: N/A

Pre-menopause/menopause: Yes. Vasomotor symptoms: Yes.

Hormone replacement therapy: No.

Condom use: No.

Vaginal douches: No.

Level of satisfaction with sexual activity: good

History of sexual assault: no

Contraceptive use: N/A.

Previous method, including complications, reason discontinued: Same method.

Cervical and vaginal cytology: 2013. Normal

Most recent PAP Smear: Normal.

History of abnormal PAP Smear? Denies.

History of sexually transmitted infections: She denies having had any sexually transmitted disease.

Vaginitis: Denies. History of Pelvic inflammatory disease? Denies.

Any difficulty conceiving in the past? Denies.

Sexually active: Yes, she has a fixed partner for the last 35 years.

History of sexual abuse or sexual assault: Denies.

Obstetric history:

G 1

T 1

P 0

A 0

L 1

Describe any maternal, fetal, or neonatal complications? Denies.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies fever, chills or malaise. Denies low energy in the past two weeks as identified in the PHQ-9 questionnaire. Denies weight loss, change of appetite.

NEUROLOGIC: Denies headache, changes in LOC, history of tremors or seizures, weakness, numbness, dizziness, headaches. Denies trouble walking, syncope, sleep disorder, memory problems.

PSYCHIATRIC: Mood was euthymic, not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, trouble falling or staying asleep. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.

HEENT: Head: Denies head injuries, or change on LOC. Eyes: No irritation, no drainage, no dry eyes, no

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Faculty Comments:? MRU Soap Note Grading Rubric This sheet is to help you understand what is required, and what the margin

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