A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform

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 (0.2 POINT)	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 (at least two references, one of which needs to be up to date 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
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

· Pertinent Positives and Negatives if it relates to the differential diagnosis of the chief compliant

Past history (include dates):

PMH

· (Chronic illness (date of onset), hospitalizations (dates), number and gender of sexual partners, risky sexual practices)

· 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,

Contraceptive history, and sexual history)

Obstetrical History

· (Gravida-Para-TPAL)

Menstrual History

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

Contraceptive History

· The types of contraceptive being used, the dates of unprotected sex)

Sexual History

· (Five P’s: Partners, Practices, Prevention of Pregnancy, Protection from STI’s, and history of STI’s)

Pregnancy and Birth History

· Maternal health: Gestational or chronic illness (i.e., gestational diabetes, preeclampsia) complications during pregnancy, infections, drugs, alcohol, illicit drug use, and medications.

· Gestational age at delivery

· Labor and delivery length: Length of labor, fetal distress, type of delivery (vaginal or cesarean)

· Neonatal period: Apgar scores, need for intensive care, jaundice, birth injuries, length of stay, birth weight.

Developmental History

· Age at which milestones were achieved and developmental abilities

· School- present grade, specific problems, interaction with peers

· Behavior – enuresis, temper tantrums, thumb sucking, pica, nightmares

Feeding History

· Breast or bottle fed, types of formula, frequency and amount, reasons for any changes in formula

· Solids – when introduced, problems created by specific types

· Fluoride use

Health Promotion/Maintenance

· Immunizations, Eye exams, dental exams, lead screening, lipid,

Hemoglobin. Colonoscopy, Annual Physical, Mammography,

PAP, Functional Status: ADLs and IADLs

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

Grandparents

Parents

Siblings

Children

Social History:

Cultural Background

Spiritual History/Religious Affiliation and Practices

Complementary/Alternative Care Practices:

Activities of Daily Living/Hobbies/Interests

Type of Family (Nuclear, Extended etc.)

Occupation of parents

Work History

Financial History

Diet

Exercise

Use of alcohol, smoking, or recreational drugs

Living Arrangements and conditions- school/daycare

Travel History

Social Support

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 and percentile on growth chart:

Wt and percentile on growth chart:

BMI (if applicable):

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:

Anticipatory Guidance:

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 M Evaluation 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

For new pick the lowest of the 3 levels

For established: drop the lowest level then pick 2nd lowest level

ANALYSIS

Write 1-2 paragraph summary listing the subjective and objective data that supports your main diagnosis.

Write 1-2 paragraph summary discussing the plan for the main diagnosis.

GENERAL FORMAT REQUIREMENTS:

References:

1. Analysis must have support from the literature with references within the last 5 years and/or use of clinical evidence-based guidelines. There should be sufficient number of references which are up to date preferably primary sources, research, clinical guidelines etc.

2. Use of APA style of references in reference list

Writing Style:

1. Writing should be clear and concise with appropriate use of medical terminology.

2. Sections identifying subjective data, objective data, assessment, and plan are written in brief short phrases; not full sentences. No need to use the word “patient.”

3. Demonstrate your clinical judgment and decision making and the evidence you are using to support your identification of the diagnoses, health problem, or differential diagnoses and management plan.

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