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

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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

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

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SOAP Note Rubric

SOAP Note Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeDemographics

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 >0.0 pts

Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)

0 pts

Missing criteria and/or submission.

1 pts

This criterion is linked to a Learning OutcomeChief Complaint (Reason for seeking health care)

4 to >3.0 pts

Includes a direct quote from patient about presenting problem

3 to >2.0 pts

Includes a direct quote from patient and other unrelated information

2 to >0.0 pts

Includes information but information is NOT a direct quote

0 pts

Missing criteria and/or submission.

4 pts

This criterion is linked to a Learning OutcomeHistory of the Present Illness (HPI)

5 to >3.0 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 >2.0 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 >0.0 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

This criterion is linked to a Learning OutcomeAllergies

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 >1.0 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 >0.0 pts

If allergies are present, students lists only the type of allergy name

0 pts

Missing criteria and/or submission.

2 pts

This criterion is linked to a Learning OutcomeReview of Systems (ROS)

15 to >8.0 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 >3.0 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 >0.0 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

This criterion is linked to a Learning OutcomeVital 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 >1.0 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 >0.0 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

This criterion is linked to a Learning OutcomeLabs

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 >1.0 pts

Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.

1 to >0.0 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

This criterion is linked to a Learning OutcomeMedications

4 to >2.0 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 >1.0 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 >0.0 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

This criterion is linked to a Learning OutcomePast Medical History

3 to >2.0 pts

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and

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