Purpose
You have had a few weeks to practice focused and general SOAP notes. While each new SOAP note also counts as practice, from here on 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.
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
- Using the guidelines in the overview and the provided templateDownload provided template, write a comprehensive SOAP note. Only one well visit permitted for comprehensive SOAP note assignments (per semester).
- Review your note for accuracy, privacy protection, and thoroughness.
Submission Instructions
By the due date indicated, submit your work.
Grading Criteria
Your work will be assessed according to the associated rubric.
Rubric
SOAP Note 4 - Comprehensive
| Criteria | Ratings | Pts |
|---|---|---|
This criterion is linked to a Learning OutcomeS - Subjective Data | 10 to >8.0 ptsExcels : Contains required elements for identity, chief complaint, 8 HOPI/6 pain, PMH allergies medications immunization status, relevant previous test screenings, major illness/hospitalizations and surgical history, family medical history, social history, safety assessment, and 14 elements for Review of Systems.8 to >7.0 ptsFulfills : Contains elements for identity and chief complaint. 6 or 7 HOPI, 4-5 pain elements. Has allergies and medications but missing past major illness or hospitalization history. Includes either FMH or Social history but not both. Safety assessment documented. 10-12 elements for Review of Systems. 7 to >5.0 ptsApproaching : Contains elements for identity, chief complaint present, 4 elements for HOPI/3 elements for pain, either FMH or social history but not both, has 5-7 elements for Review of Systems.5 to >0 ptsDeficient : Contains some elements but missing important information such as categories, allergies, PMH surgical history, FMH social history, safety assessment, 0-4 elements for a Review of Systems. | 10 pts |
This criterion is linked to a Learning OutcomeO - Objective Data | 10 to >8.0 ptsExcels : Assessment data is objective and appropriately documented covering 12 systems for complete head to toe exam.8 to >7.0 ptsFulfills : Assessment data is objective covering 10 systems for complete head to toe exam. 7 to >5.0 ptsApproaching : Assessment is missing appropriate documentation with fewer than 10 systems for complete head to toe exam.5 to >0 ptsDeficient : Assessment data is largely incomplete and insufficient and does not provide appropriate documentation. | 10 pts |
This criterion is linked to a Learning OutcomeA - Assessment | 10 to >8.0 ptsExcels : Diagnosis provided including ICD 10 code. Diagnosis is supported by evidence in Subjective and Objective content. Minimum of 3 Differential diagnosis are also provided (except for well visits). Each diagnosis is listed in numbered format with differential to right marked DD. Does not use \rule out.\8 to >7.0 ptsFulfills : Diagnosis is provided with ICD code. Good support for diagnosis in subjective objective data but may be missing one or two key elements. 2 differential diagnosis provided(except for well visits) and no evidence of writing rule out. 7 to >5.0 ptsApproaching : Diagnosis is provided but not stated in codable diagnosis but not written as rule out. Some information supports stated diagnosis but is missing pertinent data. 1 or 2 differential diagnoses given (except for well visits).5 to >0 ptsDeficient : Diagnosis is missing or there is no ICD 10 code provided or states \rule out.\ The diagnosis is not supported with subjective and objective data. No differential diagnosis is provided (except for well visits). Lacks organization and clarity. | 10 pts |
This criterion is linked to a Learning OutcomeP - Plan | INSTRUCTIONSFormat
| 10 pts |
This criterion is linked to a Learning OutcomeQuality of Documentation | 10 to >8.0 ptsExcels : Overall documentation is written with clarity and organization. Assessment provides evidence to support diagnosis and considers differential diagnosis options.8 to >7.0 ptsFulfills : Documentation is written with some need to improve organization and clarify ideas. Assessment data meets minimal expectations for supporting diagnosis. A differential is considered. 7 to >5.0 ptsApproaching : Documentation has multiple areas needing correction for organization and clarity. Assessment weakly supports diagnosis.5 to >0 ptsDeficient : Documentation is unclear and difficult to follow or comprehend. Assessment does not support diagnosis and differential diagnosis is missing. |