Instructions: Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.

Accomplished

Symptom analysis is well organized, with C/C, OLDCART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, and relevant with no extraneous data.

Satisfactory

Symptom analysis well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Some extraneous data present and/or one minor data point missing.

Needs Improvement

Symptom analysis is not well organized. Data is missing. There is too much extraneous data and/or 2-3 minor data points missing.

Unsatisfactory

Symptom analysis is inadequate, is not organized. Objective or other data is mixed into the subjective data. Important data is missing.

Accomplished

Complete, concise, well organized, and well written and includes pertinent positive and pertinent negative physical findings. Organized by body system in list format. No extraneous data.

Satisfactory

All relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format.

Needs Improvement

Omitted important relevant exams and/or not in list format.

Unsatisfactory

Omitted important relevant exams and/or subjective data are included. Lacking organization.

Accomplished

Diagnosis and differential dx are correct with ICD code and supported by subjective and objective data.

Satisfactory

Diagnosis is correct with ICD codes and is supported by subjective and objective data, however, the most accurate differential diagnosis is not listed according to subjective and objective data.

Needs Improvement

Diagnosis is correct but either does not include ICD code or is missing two or more important differential diagnoses according to the subjective and objective data provided.

Unsatisfactory

Diagnosis is not correct, is not provided, or is not reflective of the subjective and objective data provided.

Accomplished

Plan is organized, complete, and evidence-based according to the National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).

Satisfactory

Plan is organized, complete, and evidence-based according to the National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching but may be missing 1-2 minor points.

Needs Improvement

Plan is less organized and not based on evidence according to the National Standards of Care. Does not address each diagnosis or may not be individualized to the specific patient. Missing medication teaching or one of the 5 components.

Unsatisfactory

No Plan is provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching.