Read over the SOAP note and formulate a primary diagnosis.? Based on the diagnosis complete the SOAP note with the details that would be expected for the dia

SOAP NOTE GRADING RUBRIC

Guidelines:

1-Use the case study in the description to complete the assignment. Fill in the missing details for each required section that would be expected for the diagnosis.

SUBJECTIVE Analysis (0.2 POINT)	Score received
1-Subjective section should include: a-Chief complaint (CC) b-History of present illness (HPI)- All 7 attributes (location, quality, quantity or severity, timing including onset, frequency, and duration, setting in which it occurs, aggravating or relieving factors, and associated symptoms) c-Past history (Medical, Surgical, Obstetric/Gynecology, Psychiatric) d-family history (3 generation pedigree of first-degree relatives, i.e. parents, siblings, children) e. Personal and social history (i.e. sexual history 5p’s) f. Review of systems (ROS, pertinent positives and/or negatives) g. Developmentally appropriate-i.e. developmental history if peds, functional assessment and/or dementia screen if elderly a-Identified and collected the necessary data b-Categorized and organized data using the appropriate format c-Incorporated all pertinent data/facts d- Used proper documentation and proper billing code e- PATIENT’S CULTURE MUST BE NOTED
OBJECTIVE (0.2POINT)	Score received
1-Objective section should include: a. General survey b. Vital Signs (including BMI and growth chart if applicable) c. All other necessary body systems d. Diagnostic test if available a. Identified and collected the necessary data b. Categorized and organized data using the appropriate format c.Incorporated all pertinent data/facts d. Used proper documentation and billing code
ASSESSMENT (0.2 POINT)	Score received
1- Identified correct diagnosis, ICD-10 code, and correct differential diagnosis a-Filtered relevant data from irrelevant data b.-Interpreted relationships/patterns among data (e.g., noted trends) c.Integrated information to arrive at diagnosis d.Identified risk factors d. Used proper documentation
PLAN Analysis (0.2POINT)	Score received
a-Recommended an appropriate plan for each problem b-Included recommendations for non-drug and drug therapy c-Included recommendations for monitoring d- Included health education e- Included followup & referrals f- include cultural considerations of patient care Incorporate the patient's culture on the demographic section on SOAP notes.
FORMAT (0.2 POINT)	Score received
1- APA 2- References Current (atleast two references, one of which needs to be uptodate and the other a clinical practice guideline from a peer reviewed journal article or national organization such as AAFP, ACOG, USPSTF) 3- Writing clear, concise 4- Summary/Conclusion
TOTAL: /1

 

SOAP FORMAT & RUBRIC

Initials of Patient:

Patient Age:

Patient Ethnicity:

Initials of Provider:

Clinical Setting:

Patient Status: ____New ____Established

SUBJECTIVE DATA; GRADE RECEIVED: _____

Overall Instructions:

1. Identified and collected the necessary data

2. Categorized and organized data using the appropriate format

3. Incorporated all pertinent data/facts

4. Used proper documentation

5. LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient

6. Identify cultural influences on care

FORMAT

Chief Complaint:

History of Present Illness:

Location

Quality

Quantity or Severity

Timing (Onset, Duration, Frequency)

Setting

Aggravating and relieving Factors

Associated Symptoms

Past history (include dates):

PMH

· Chronic illness (date of onset) & hospitalizations (dates) Medications: Dose, route, frequency

· Allergies: Medications, Foods, Other Allergens

PSH

· (Dates, indications, and types of operations)

Past Psychiatric Hx

· (Illness and timeframe, diagnosis, hospitalizations and treatments)

Obstetrical/Gynecological (obstetric history & menstrual history) Obstetrical History

· (Gravida-Para-TPAL)

Menstrual History

· (Menarche, LMP, PMP, regular/irregular, frequency, duration, quality of flow, Menopause, Post-menopausal bleeding, HRT)

Health Promotion/Maintenance: Colonoscopy, Prostate (PSA), BP

check, Cholesterol, Annual Physical, Mammography, PAP, Eye

Exam, Dental etc., Immunizations

Functional Status: ADLs and IADLs

Family History: Alive, Deceased, Age, Diseases, Health Conditions that place patient at risk (ages)

Parents

Siblings

Children

Social History:

Cultural Background

Spiritual History/Religious Affiliation and Practices

Complementary/Alternative Care Practices:

Type of Family (Nuclear, Extended etc.)

Marital Status

Parental Status

Work History

Financial History

Diet

Exercise (Frequency, intensity, Time, Type)

Stress Management

Sleep

Social Support

Sexual history (5ps)

Use of alcohol, smoking, or recreational drugs

Living Arrangements

Travel History

Review of Systems:

Constitutional:

Head/face:

Eyes:

Ears:

Nose:

Mouth/Throat/ Neck:

Respiratory:

Cardiac:

Breast:

GI:

GU:

GYN (female):

Reproductive (Male):

Musculoskeletal:

Skin/Integument:

Psychiatric:

Neuro:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Determine Which LEVEL of HISTORY (Choose one):

Focused HPI (1-3 findings); ROS N.A; PFSH N.A

Expanded HPI (1-3 Findings); ROS 1 or more; PFSH N.A.

Detailed HPI (4 or more findings); ROS 2-9 systems; PFSH one

Comprehensive HPI (4 or more findings or status of 3 or more chronic stable conditions; ROS 10-14; PFSH 2-3 areas

OBJECTIVE DATA; Grade received_____

Overall Instructions:

1. Identified and collected the necessary data

2. Categorized and organized data using the appropriate format

3. Incorporated all pertinent data/facts

4. Used proper documentation

5. LIST at the end of your subjective section the billing level : Problem Focused, Expanded problem focused, detailed, comprehensive (use guidelines for new vs. established patient

FORMAT:

Vital Signs:

Oxygen Saturation:

Ht:

Wt:

BMI:

Constitutional:

General:

Physical Examination:

Head/face:

Eyes:

Ears:

Nose:

Mouth/Throat/ Neck:

Respiratory:

Cardiac:

Breast:

GI:

GU:

GYN (female):

Reproductive (Male):

Musculoskeletal:

Skin/Integument:

Psychiatric:

Neuro:

Hematologic/Lymphatic/Immunologic:

Determine Billing LEVEL OF PHYSICAL OBJECTIVE EXAM (choose one):

Focused: 1 body area or organ system (1-5 elements);

Expanded problem focused (2-4 body are or organ system (6-11 elements);

Detailed (5-7 see notes);

Comprehensive (8 organ systems see notes);

Laboratory Data Already Ordered and Available for Review (If not done will go in plan):

Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go in plan):

ASSESSMENT; GRADE RECEIVED____

1) Main Diagnosis/Problem:

2) Additional Health Problem/Dx:

3) Differential Diagnoses for top diagnoses

4) Identify Risk Factors

PLAN; GRADE RECEIVED________

For Each Diagnosis or Health Problem Identified as Appropriate:

Additional Laboratory Tests or Diagnostic Data Needed

Pharmacologic Management:

Drug, dose, route, frequency, Disp amount

SIG (write like a prescription)

Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit etc.

Complementary Therapies:

Health Education:

Referrals:

Follow-up Appointment:

For the Encounter Final Level of Decision Making: (give rationale for level which is based on Hx, physical, Decision making); Choose one

Straightforward:

Low Complexity:

Moderate Complexity:

High Complexity:

Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems Reviewed and Level of Physical Exam.

Patient Status: New or established

Level of history

Level of physical (exam)

Level of Medical decision making

,

3. Medical Decision Making

Number of Diagnoses or Treatment Options

Identify each problem or treatment option mentioned in the record. Enter the number in each of the categories in Column B in the table below. (There are maximum number in two categories.)

Number of Diagnoses or Treatment Options A B X C = D

Problem(s) Status Number Points Result

Self-limited or minor (stable, improved or worsening) Max = 2 1 Est. problem (to examiner); stable, improved 1

Est. problem (to examiner); worsening 2

New problem (to examiner); no additional workup planned

Max = 1

3

New prob. (to examiner); add. workup planned 4

TOTAL Multiply the number in columns B & C and put the product in column D. Enter a total for column D.

Bring total to line A in Final Result for Complexity (table below)

Amount and/or Complexity of Data Reviewed

For each category of reviewed data identified, circle the number in the points column. Total the points.

Amount and/or Complexity of Data Reviewed Reviewed Data Points

1

1

1

1

1

2

2

Review and/or order of clinical lab tests

Review and/or order of tests in the radiology section of CPT

Review and/or order of tests in the medicine section of CPT

Discussion of test results with performing physician

Decision to obtain old records and/or obtain history from someone other than patient

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

Independent visualization of image, tracing or specimen itself (not simply review of report)

TOTAL Bring total to line C in Final Result for Complexity (table below)

Use the risk table below as a guide to assign risk factors. It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide. Circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled. Enter the level of risk identified in Final Result for Complexity (table below).Risk of Complications and/or Morbidity or Mortality

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered

Management Options Selected

Minimal • One self-limited or minor problem,

e.g., cold, insect bite, tinea corporis

• Laboratory tests requiring venipuncture • Chest x-rays • EKG/EEG • Urinalysis • Ultrasound, e.g., echo • KOH prep

• Rest • Gargles • Elastic bandages • Superficial dressings

Low

• Two or more self-limited or minor problems • One stable chronic illness, e.g., well controlled

hypertension or non-insulin dependent diabetes, cataract, BPH

• Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

• Physiologic tests not under stress, e.g.,pulmonary function tests

• Non-cardiovascular imaging studies with contrast, e.g., barium enema

• Superficial needle biopsies • Clincal laboratory tests requiring arterial puncture • Skin biopsies

• Over-the-counter drugs • Minor surgery with no identified risk factors • Physical therapy • Occupational therapy • IV fluids without additives

Moderate

• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

• Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis, e.g., lump in breast

• Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis

• Acute complicated injury, e.g., head injury with brief loss of consciousness

• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

• Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no

identified risk factors, e.g., arteriogram cardiac cath • Obtain fluid from body cavity, e.g., lumbar puncture,

thoracentesis, culdocentesis

• Minor surgery with identified risk factors • Elective major surgery (open, percutaneous or

endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • IV fluids with addititives • Closed treatment of fracture or dislocation without

manipulation

High

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

• Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

• An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss

• Cardiovascular imaging studies with contrast with identified risk factors

• Cardiac electrophysiological tests • Diagnostic endoscopies with identified risk factors • Discography

• Elective major surgery (open, percutaneous or endoscopic with identified risk factors)

• Emergency major surgery (open, percutane

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