Overview
Module 7 Assignment i Cont'd.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below. SOAP Note TemplateDownload SOAP Note Template
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 |
Submission Instructions:
- Your SOAP note should be clear and concise, and students will lose points for improper grammar, punctuation, and misspellings.
- You must use the template provided. Turnitin will recognize the template and not score against it.
- Your submission will be reviewed for plagiarism through Turnitin. Similarity reports above 20% will not be accepted. Resubmit if that is the case. You will have 3 opportunities to resubmit for similarity above 20%.
- Turnitin will also assess for Artificial Intelligence (AI) generated text. AI reports are not visible to students, but students will be notified and provided with reports that show higher than 20% as they will not be accepted.
- Late work policies, expectations regarding proper citations, acceptable means of responding to peer feedback, and other expectations are at the discretion of the instructor.
- You can expect feedback from the instructor within 48 to 72 hours from the Sunday due date.
Rubric Details:
- Chief Complaint 4 Points- Includes a direct quote from the patient about the presenting problem.
- Demographics 2 Points- Begins with patient initials, age, race, ethnicity, and gender (5 demographics).
- History of the Present Illness 5 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).
- Allergies 2 Points- Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present), reports for each severity of the allergy, AND a description of the allergy.
- Review of Systems 12 Points- Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to the chief complaint, AND uses the words “admits” and “denies”.
- Vital Signs 2 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).
- Labs 3 Points- Includes a list of the labs reviewed at the visit, values of lab results, and highlights abnormal values. (This refers to the previous visit's labs, and it is different than labs or diagnostics ordered during this specific visit).
- Medications 4 Points- Includes a list of all of the patient-reported medications and the medical diagnosis for the medication (including name, dose, route, and frequency).
- Screenings 3 Points- Includes an assessment of at least 5 screening tests. Enter the name of each screening, the date performed, and the results for each of them. You should also enter the immunization status according to age.
- Past Medical History 3 Points- Includes (Major/Chronic, Trauma, Hospitalizations) for each medical diagnosis, year of diagnosis, and whether the diagnosis is active or current.
- Past Surgical History 3 Points- Includes, for each surgical procedure, the year of the procedure and the indication for the procedure.
- Family History 3 Points- Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease, and cancer.
- Social History 3 Points-Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
- Physical Examination 12 Points- Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to the chief complaint.
- Diagnosis 5 Points- Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority).
- Differential Diagnosis 5 Points- Includes at least 3 differential diagnoses for the principal diagnosis
- Pharmacologic Treatment Plan 5 Points- 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 agents. If the diagnosis is a chronic problem, the student includes instructions on currently prescribed medications as above. Include a detailed prescription for each medication ordered. (The education provided in this section will not be part of the education section).
- Diagnostic/Lab Testing 5 Points-Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
- Education 5 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. Medication instructions will not be measured on this rubric.
- Anticipatory Guidance 4 Points-Includes at least 3 primary prevention strategies (related to age/condition [i.e., immunizations, pediatric and prenatal milestone anticipatory guidance]) and at least 2 secondary prevention strategies related to age/condition [i.e., screening]. Separate education from anticipatory guidance. They will be evaluated individually.
- Follow-up plan 4 Points-Includes recommendation for follow-up, including time frame (i.e., x # of days/weeks/months).
- References 3 Points- High level of APA precision.
- Grammar 3 Points-Free of grammar and spelling errors.