Week 8 SOAP Note Assignment
This week, you will submit a SOAP note.
- Select a “patient” (friend or family member) on whom to perform a complete H&P.
- NOTE: DO NOT USE REAL NAMES OR INITIALS OR OTHERWISE IDENTIFY YOUR “PATIENT.” FAILURE TO MAINTAIN PRIVACY WILL RESULT IN A FAILING SCORE.
- Using the format specified below, write a 1 to 2 page SOAP note on your “patient.” The HPI should be presented in a paragraph, and the rest of the data including the ROS should be presented in a list format.
- Collect only the information that is pertinent to the chief complaint of the patient to include in your SOAP note. Aim for a single page using normal margins and format.
- The SOAP Note must contain all required elements as outlined in the rubric below.
- You must self-score your SOAP note using the rubric and attach it to the assignment.
Subjective Data
· Biographic Data:– Age/race/gender, date, occupation, language/communication needs.
· Source – and reliability
· Chief Complaint (reason for seeking care)- make every attempt to use patient’s own words.
· History of Present Illness (HPI)- complete, clear, chronological account of events prompting patient to seek care. Use OLDCARTS or PQRST to gather data but do not include acronym in HPI. Document in paragraph format.
· Past Medical History (PMH)- childhood, adult illnesses, serious illnesses/hospitalizations, obstetric hx, Immunizations, last exam
· Allergies, medication, food, environmental
· Medications- Rx, OTC, herbal, etc.
· Family History- write a genogram diagram or outline; age, health, age, and cause of death of each family member going back three generations.
· Personal and Social History- interests, support systems, occupation, highest level of education, job history, financial situation, spiritual beliefs, lifestyle, alternative health care practices, sexual and obstetric history.
· Review of Systems (ROS)- series of questions from head to toe. Must be in the following order – include health promotion practices:
· General Survey
· Integumentary
· Head, Eyes, Ears, Nose, and Throat
· Neck/thyroid
· Breasts and axillary lymph nodes
· Respiratory
· Cardiovascular
· Peripheral vascular
· Gastrointestinal
· Genitourinary
· Genital/Reproductive system
· Sexual health
· Musculoskeletal
· Neurological (must include reflexes on PE)
· Hematologic
· Endocrine
· Functional assessment – include activities of daily living
· Self-esteem/self-concept
· Activity/exercise
· Sleep/rest/nutrition, include
· Nutritional status assessment- identify if patient is at risk for malnutrition or over nutrition
· Interpersonal relationships
· Spiritual resources
· Coping and stress management
· Personal habits – alcohol, tobacco, street drugs
· Environment/Hazards
· Intimate partner violence
· Occupational health
· Perception of health
· Developmental Competence – children, pregnant women, older adult
Objective data
· Physical Examination (PE)
· General Survey
· Integumentary
· Head, Eyes, Ears, Nose, and Throat
· Neck/thyroid
· Breasts and axillary lymph nodes
· Respiratory
· Cardiovascular
· Peripheral vascular
· Gastrointestinal
· Genitourinary
· Genital/Reproductive system
· Sexual health
· Musculoskeletal
· Neurological (must include reflexes on PE)
· Hematologic
· Endocrine
Assessment
· Diagnosis with rationale
· Differential diagnosis with rationales
Plan
· Dx plan – include diagnostic tests needed (lab, x-ray, etc.)
· Tx plan – include recommended treatment – cite national guidelines
· Patient education – including specific medication teaching
· Referral/Follow up
· Health Maintenance – include health promotion recommendations from AHRQ (ePSS app) according to age/gender/conditions
SOAP NOTE RUBRIC |
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0-5 points |
6-10 points |
11-15 points |
16-20 points |
21-25 points |
Student Score |
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SUBJ |
Data is not organized. Objective is mixed into the subjective data. |
Data is not well organized. The complete pre-conceived differential considered is incomplete. Data is missing. |
Data is well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. It is clear to the reader that information is gathered to include/exclude options in the differential. Too much extraneous data |
Data is well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Little extraneous data may be present. |
Complete, concise, relevant without extraneous data. All data needed to support differential is present with no extraneous data. |
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OBJ |
Subjective data is included. |
Not all relevant exams were done. |
All relevant exams were done but not thoroughly. |
All relevant exams were done thoroughly but extraneous exams were also done. |
Complete, concise, well-organized and well-written. |
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DDX |
No assessment provided. |
Assessment present but mixed with other problems that are not reflective of S/0. Appears to be preceptor’s diagnosis. |
Assessment reflects information in S/O data but does not include correct differential. |
Each problem identified has a differential that is reflected in S/O. Differential/problems are not prioritized correctly. |
Assessment and prioritized differential accurate and supported. Demonstrates exceptional critical thinking. |
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PLAN |
No Plan provided |
Plan present but does not address all problems identified. Appears to be preceptor’s plan. |
Plan addresses all problems but some interventions are not evidence-based. |
Plan is organized but fails to address any of: barriers to compliance needs for education plan for preventive complete plan for follow up. |
Plan is complete prioritized, and demonstrates exceptional critical thinking. Counseling on despair was accomplished. |
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Total Score: |