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 be

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Distinguised Excellent Fair Poor

Includes a direct quote from patient about presenting problem

Includes a direct quote from patient and other unrelated information

Includes information but information is NOT a direct quote

Information is completely missing

4 Points 3 Points 2 Points 0 Points Begins with patient initials, age, race, ethnicity and gender (5 demographics)

Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)

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

2 Points 1.5 Points 1 Points 0 Points

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS –

Onset, Location, Duration, Character, Aggravating factors, Relieving factors,

Timing and Severity)

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)

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)

Information is completely missing

5 Points 3 Points 2 Points 0 Points

Includes NKA (including = Drug, Environemental, Food, Herbal, and/or Latex or if allergies are present (reports for each

severity of allergy AND description of allergy)

If allergies are present, students lists type Drug, environemtal factor, herbal, food, latex name and

includes severity of allergy OR description of allergy

If allergies are present, students lists only the type of allergy name Information is completely missing

2 Points 1.5 Points 1 Points 0 Points

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”

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”

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”

Information is completely missing

12 Points 6 Points 3 Points 0 Points

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.)

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.)

Includes 6 or less 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.)

Information is completely missing

2 Points 1.5 Points 1 Points 0 Points

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.

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

abnormal values.

Includes a list of the labs reviewed at the visit but does not include the values of lab results or

highlight abnormal values. Information is completely missing

3 Points 2 Points 1 Points 0 Points Includes a list of all of the patient reported medications and the medical diagnosis for

the medication (including name, dose, route, frequency)

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)

Includes a list of all of the patient reported medications (including 2 of the 4: name, dose,

route, frequency) Information is completely missing

Subjective

Objective

Medications

Labs

Review of Systems (ROS)

History of the Present Illness (HPI)

Demographics

Chief Complaint (Reason for seeking health care)

Allergies

Vital Signs

4 Points 2 Points 1 Points 0 Points Includes an assessment of at least 5

screening tests Includes an assessment of at least 4 screening

tests Includes an assessment of at least 3 screening

tests Information is completely missing

3 Points 2 Points 1 Points 0 Points

Includes (Major/Chronic, Trauma, Hospitaliztions), for each medical diagnosis, year of diagnosis and whether the diagnosis

is active or current

Includes (Major/Chronic, Trauma, Hospitaliztions), for each medical diagnosis,

either year of diagnosis OR whether the diagnosis is active or current

Includes each medical diagnosis but does not include year of diagnosis or whether the

diagnosis is active or current Information is completely missing

3 Points 2 Points 1 Points 0 Points

Includes, for each surgical procedure, the year of procedure and the indication for the

procedure

Includes, for each surgical procedure, the year of procedure OR indication of the procedure

Includes, for each surgical procedure but not the year of procedure or indication of the procedure Information is completely missing

3 Points 2 Points 1 Points 0 Points Includes an assessment of at least 4 family members regarding, at a minimum, genetic

disorders, diabetes, heart disease and cancer.

Includes an assessment of at least 3 family members regarding, at a minimum, genetic

disorders, diabetes, heart disease and cancer.

Includes an assessment of at least 2 family members regarding, at a minimum, genetic

disorders, diabetes, heart disease and cancer. Information is completely missing

3 Points 2 Points 1 Points 0 Points

Includes all of the following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous

occupation, sexual orientation, sexually active, contraceptive use, and living

situation.

Includes 10 of the 11 following: tobacco use, drug use, alcohol use, marital status, employment

status, current/previous occupation, sexual orientation, sexually active, contraceptive use,

and living situation.

Includes 9 or less of the following: tobacco use, drug use, alcohol use, marital status, employment

status, current/previous occupation, sexual orientation, sexually active, contraceptive use,

and living situation.

Information is completely missing

3 Points 2 Points 1 Points 0 Points

Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint

Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems

directed to chief complaint

Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems

directed to chief complaint Information is completely missing

12 Points 6 Points 3 Points 0 Points

Includes a clear outline of the accurate principal diagnosis AND lists the remaining

diagnoses addressed at the visit (in descending priority)

Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority

Includes an inaccurate diagnosis as the principal diagnosis Information is completely missing

5 Points 3 Points 2 Points 0 Points

Includes at least 3 differential diagnoses for the principal diagnosis

Includes 2 differential diagnoses for the principal diagnosis

Includes 1 differential diagnosis for the principal diagnosis

Information is completely missing

5 Points 3 Points 2 Points 0 Points

Diagnosis

Assessment

Plan

Family History

Screenings

Past Medical History

Differential Diagnosis

Social History

Past Surgical History

Physical Examination

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of

the following: drug name, dose, route, frequency, duration and cost as well as

education related to pharmacologic agent. If the diagnosis is a chronic problem, student

includes instructions on currently prescribed medications as above.

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under

“assessment”. The plan includes 4 of the following 7: the drug name, dose, route,

frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under

“assessment”. The plan includes less than 4 of the following: the drug name, dose, route,

frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis

is a chronic problem, student includes instructions on currently prescribed medications

as above.

Information is completely missing

5 Points 3 Points 2 Points 0 Points Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no

diagnostic testing clinically required at this time”

Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic

testing clinically required at this time”

Includes appropriate diagnostic testing less than 50% of the time. Information is completely missing

5 Points 3 Points 2 Points 0 Points

Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how

to incorporate healthy behaviors into their lives.

Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.

Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives.

Information is completely missing

5 Points 3 Points 2 Points 0 Points

Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal

milestone anticipatory guidance)) and at least 2 secondary prevention strategies

(related to age/condition (i.e. screening))

Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory

guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e.

screening))

Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory

guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e.

screening))

Information is completely missing

4 Points 2 Points 1 Points 0 Points Includes recommendation for follow up,

including time frame (i.e. x # of days/weeks/months)

Includes recommendation for follow up, but does not include time frame (i.e. x # of

days/weeks/months) Does not include follow up plan

4 Points 2 Points 0 Points 0 Points

High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing

3 Points 2 Points 1 Points 0 Points

Free of grammar and spelling errors Writing mechanics need more precision and attention to detail

Writing mechanics need serious attention

3 Points 2 Points 0 Points 0 Points

Pharmacologic treatment plan

Follow up plan

Writing

Grammar

References

Diagnostic/Lab Testing

Anticipatory Guidance

Education