Cassava Kitchen

Purpose

You have had a few weeks to practice focused and general SOAP notes. While each new SOAP note from here on will also count as practice, we are expecting a higher minimum standard.

Overview

Remember that SOAP notes promote organization of thinking and use of the Nursing Process. Continue to use the template provided and follow the rubric for guidance.

Information submitted must not include any confidential identifying patient information.

Focused SOAP Notes

Usually, we describe a focused (or episodic) visit as when a patient comes in who is ill with a complaint such as URI or UTI. The patient may be someone who also comes in for chronic condition visits, but this particular visit is focused on the chief complaint. It is helpful to differentiate between the types of visits the same person might make. For example, when your diabetic patient comes in because of a UTI, you are only focusing on the “sick or illness” complaint.

Comprehensive SOAP Notes

A comprehensive SOAP note is describes an office visit that is more thorough not focused on just one complaint. This may be an annual physical exam or follow up on chronic condition(s). It involves assessment of more body systems. For example, for a routine follow up on diabetes, you will want the patient to schedule a different appointment.

The rubrics will also help you see how the two types of SOAP notes differ.

Please note: When documenting assessment or review of systems, use proper descriptive terms. Do not write “normal” or “negative” in the assessment.

When you get into practice, it will be important to understand that billing for services will depend on having proper documentation in all areas of the patient’s chart. When a patient is charged for services and the chart does not support the billing code, it can be considered fraudulent and serious consequences could result.

Please be sure to put your own name on the assignment being submitted.

When you get into practice, it will be important to understand that billing for services will depend on having proper documentation in all areas of the patient’s chart. When a patient is charged for services and the chart does not support the billing code, it can be considered fraudulent and serious consequences could result.

To avoid violating HIPAA guidelines, do not use the patient’s name, address, or SSN. Please be sure to put your own name on the assignment being submitted.

Action Items

1. Using the guidelines in the overview and the provided templateDownload provided template, write a focused SOAP note.
2. Review your note for accuracy, privacy protection, and thoroughness.

   Grading Criteria

   Your work will be assessed based on the associated grading rubric.

   Rubric

   SOAP Note 1 - Focused

   SOAP Note 1 - Focused

   Criteria	Ratings	Pts
   This criterion is linked to a Learning OutcomeS - Subjective Data	10 to >8.0 ptsExcels : Contains chief complaint, 3 elements in HOPI, all pertinent ROS included.8 to >7.0 ptsFulfills : Contains chief complaint, 2 elements in HOPI, all pertinent ROS included.7 to >5.0 ptsApproaching : Contains chief complaint, 1 element HOPI, most of pertinent ROS included.5 to >0 ptsDeficient : Insufficient chief complaint; insufficient HOPI elements lacking pertinent ROS.	10 pts
   This criterion is linked to a Learning OutcomeO - Objective Data	10 to >8.0 ptsExcels : Includes 6-11 elements in exam including all pertinent systems.8 to >7.0 ptsFulfills : Contains 4-5 elements in exam including all pertinent systems.7 to >5.0 ptsApproaching : Contains 2-3 elements in exam with most of the pertinent systems included.5 to >0 ptsDeficient : Insufficient elements in exam (less than 2) and not including pertinent systems.	10 pts
   This criterion is linked to a Learning OutcomeA - Assessment	10 to >8.0 ptsExcels : Diagnosis with proper ICD 10 coding supported by assessment findings and 3 differential diagnoses given.8 to >7.0 ptsFulfills : Diagnosis with proper ICD 10 coding, moderately strong support of assessment with exam findings, and at least 2 differential diagnoses.7 to >5.0 ptsApproaching : Diagnosis with proper ICD 10 coding, assessment weakly supports diagnosis, at least 1 differential diagnosis.5 to >0 ptsDeficient : Diagnosis not properly coded with ICD 10, poorly supported by assessment, and does not include differential diagnosis.	10 pts
   This criterion is linked to a Learning OutcomeP - Plan	10 to >8.0 ptsExcels : Plan includes appropriate diagnostic testing if indicated, appropriate medication if indicated, includes patient participation and cultural sensitivity, properly directs patient on follow-up and what to do if symptoms do not improve or get worse.8 to >7.0 ptsFulfills : Medication is appropriately prescribed, but some diagnostic testing could have been added. Patient participation or culture not considered. Directions for follow-up non-specific or vague.7 to >5.0 ptsApproaching : Medication prescribed is not incorrect but is not best option for patient, and diagnostic testing could have been included. Patient participation and cultural sensitivity only partially considered, and follow-up directions need further clarification.5 to >0 ptsDeficient : Medication is incorrect if prescribed or inappropriate. Additional testing should have been considered. There is an absence of patient participation and cultural sensitivity. Follow up directions are not included.	10 pts
   This criterion is linked to a Learning OutcomeQuality of Documentation	10 to >8.0 ptsExcels : Overall focuses SOAP note shows clarity of thinking and communication with the patient.8 to >7.0 ptsFulfills : Overall SOAP note mostly clear with some disconnected ideas or lack of support for diagnosis. Communication with patient shows average effort.7 to >5.0 ptsApproaching : SOAP note is basic brief, lacks appropriate support or communication with patient for good patient centered care.5 to >0 ptsDeficient : SOAP note is not clear, does not show support of diagnosis, and fails to show good communication or patient centered care.	10 pts