Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonst
Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
This assignment uses a template. Refer to the "Academic SOAP Note Template," located on the Student Success Center page under the AGACNP tab.
Develop a hospital follow-up progress SOAP note based on a clinical patient from your clinical/practicum setting. In your assessment, provide the following:
- A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.
- A one or two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.
- List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.
- List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.
- List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.
- List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.
- Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.
- Discussion of any relevant ethical, legal, or geriatric-specific considerations.
Incorporate at least three peer-reviewed articles in the assessment or plan.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.
© 2021. Grand Canyon University. All Rights Reserved.
Academic SOAP Note Template
Reason for Follow-Up: A one-sentence description of the primary working diagnosis that
identifies admit date or hospital day of visit, pending differential diagnoses, and context or
service in which the patient is being seen is provided and includes supporting details.
Clinical Course Summary: A one-to-two paragraph description of the current illness or hospital
stay, including pertinent diagnostic findings or procedures and the number of days since the
patient has been hospitalized, is complete with supporting documentation. (This is not the HPI.)
Review of systems: Review of the symptoms the patient or his/her family explains, organized by
system. Five systems affected by the working diagnosis, along with two positive or negative
effects of the diagnosis on each system, are provided with thorough details and support. Refer to
the H&P template for ROS options.
Physical Exam: Five systems examined within the last 24 hours, including two positive or
negative findings relevant to each system and a full set of vital signs, are provided with thorough
details and support. Refer to the H&P template for ROS options.
Laboratory and Radiology Results: List pertinent data available when seeing the patient
pertinent to the reasons for follow-up. Include normal and abnormal results and identify the
abnormalities.
Assessment: (Provide three references) Identification of all acute and chronic diagnoses in
order of ICD-10 priority and any differential diagnoses being eliminated are provided with
thorough details and support.
• Differential diagnoses: What is pending to be ruled in or ruled out? A differential is only needed if there is a sign/symptom for which you have not identified a diagnosis.
• Acute and chronic medical conditions: Include the ICD-10 diagnosis code (look in Lopes Activity Tracker).
Treatment Plan: (Provide three references) A treatment plan that corresponds with the
diagnosis and includes admission type, diagnostics, medications and dosages, and any consults
or follow-up procedures needed is provided with thorough details and support.
What orders are you starting? What medications (include dose and frequency of new meds or
changes in dose of existing meds)? What consults? Education topics? Discharge plan?
Geriatric Considerations: Based on the age, address any differences in the treatment if the
patient were younger or older.
References: Use three references listed in APA format.
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Benchmark – Academic Clinical SOAP Note 1 – Rubric
Collapse All Benchmark – Academic Clinical SOAP Note 1 – RubricCollapse All
Primary or Working Diagnosis
5 points
Criteria Description
Primary or Working Diagnosis
5. Target
5 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.
4. Acceptable
4.5 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided accurately.
3. Approaching
4 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is provided.
2. Insufficient
2.5 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is incomplete or incorrect.
1. Unsatisfactory
0 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is not provided.
Brief Clinical Course
5 points
Criteria Description
Brief Clinical Course
5. Target
5 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete with supporting documentation.
4. Acceptable
4.5 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is complete.
3. Approaching
4 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is supported with minor details missing.
2. Insufficient
2.5 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is only partially supported.
1. Unsatisfactory
0 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the patient has been hospitalized, is not provided.
Review Of Systems
5 points
Criteria Description
Review Of Systems
5. Target
5 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with thorough details and support.
4. Acceptable
4.5 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided with accurate details and support.
3. Approaching
4 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are provided but with minimal detail or support.
2. Insufficient
2.5 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are incomplete or incorrect.
1. Unsatisfactory
0 points
Five systems affected by the working diagnosis, along with two positive or negative effects of the diagnosis on each system, are not present.
Exam
5 points
Criteria Description
Exam
5. Target
5 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with thorough details and support.
4. Acceptable
4.5 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided with accurate details and support.
3. Approaching
4 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are provided but with minimal detail or support.
2. Insufficient
2.5 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are incomplete or incorrect.
1. Unsatisfactory
0 points
Five systems examined within the last 24 hours, including two positive or negative findings relevant to each system and a full set of vital signs, are not present.
Diagnostics
5 points
Criteria Description
Diagnostics
5. Target
5 points
Diagnostics within the past 24 hours are provided with thorough details and support.
4. Acceptable
4.5 points
Diagnostics within the past 24 hours are provided with accurate details and support.
3. Approaching
4 points
Diagnostics within the past 24 hours are provided but with minimal detail or support.
2. Insufficient
2.5 points
Diagnostics within the past 24 hours are incomplete or incorrect.
1. Unsatisfactory
0 points
Diagnostics within the past 24 hours are not present.
Impression or Assessment
5 points
Criteria Description
Impression or Assessment
5. Target
5 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with thorough details and support.
4. Acceptable
4.5 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided with accurate details and support.
3. Approaching
4 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are provided but with minimal detail or support.
2. Insufficient
2.5 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are incomplete or incorrect.
1. Unsatisfactory
0 points
Identification of all acute and chronic diagnoses in order of ICD-10 priority and any differential diagnoses being eliminated are not present.
Plan (B)
5 points
Criteria Description
Plan (C.7.2)
5. Target
5 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with thorough details and support.
4. Acceptable
4.5 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided with accurate details and support.
3. Approaching
4 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is provided but with minimal details or support.
2. Insufficient
2.5 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is incomplete or incorrect.
1. Unsatisfactory
0 points
A treatment plan that corresponds with the diagnosis and includes admission type, diagnostics, medications and dosages, and any consults or follow-up procedures needed is not present.
Geriatric Specific Care
5 points
Criteria Description
Geriatric Specific Care
5. Target
5 points
A discussion of ethical, legal, or geriatric considerations is provided with thorough details and support.
4. Acceptable
4.5 points
A discussion of ethical, legal, or geriatric considerations is provided with accurate details and support.
3. Approaching
4 points
A discussion of ethical, legal, or geriatric considerations is provided but with minimal details or support.
2. Insufficient
2.5 points
A discussion of ethical, legal, or geriatric considerations is incomplete or incorrect.
1. Unsatisfactory
0 points
A discussion of ethical, legal, or geriatric considerations is not present.
Mechanics of Writing
5 points
Criteria Description
Includes spelling, punctuation, grammar, language use.
5. Target
5 points
Writer is clearly in command of standard, written, academic English.
4. Acceptable
4.5 points
Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.
3. Approaching
4 points
Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.
2. Insufficient
2.5 points
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.
1. Unsatisfactory
0 points
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.
Format/Documentation
5 points
Criteria Description
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.
5. Target
5 points
No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.
4. Acceptable
4.5 points
Appropriate format and documentation are used with only minor errors.
3. Approaching
4 points
Appropriate format and documentation are used, although there are some obvious errors.
2. Insufficient
2.5 points
Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.
1. Unsatisfactory
0 points
Appropriate format is not used. No documentation of sources is provided.
Total 50 points
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