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SOAP NOTE RUBRIC
Criteria
Points
Subjective (35 points)
Chief complaint
HPI
Relevant PMH & FH
ROS
Currents: Allergies, Meds/OTCs, Tobacco, Immunizations,
Alcohol Diet, Exercise, Sleep
Objective (40 points)
5
10
5
10
5
Competent
Need
Improvement
Not
Acceptable
Provides
complete,
concise, and
accurate
information
which is well
organized and
easy to
understand.
Provides most
of the
pertinent
information,
but is not well
organized
and/or is
slightly
challenging to
understand.
May be
missing
pertinent
negative
information
(e.g., patient
denies…).
3
8
3
8
3
Limited or no
summary of
pertinent
information, is
organized
poorly,
contains
inaccurate
information,
and/or is
difficult to
understand.
Provides most
of the
pertinent
information,
but is not well
organized
and/or is
slightly
challenging to
understand.
May be
missing
pertinent
Limited or no
summary of
pertinent
information, is
organized
poorly,
contains
inaccurate
information,
and/or is
difficult to
understand.
5
10
5
10
5
Provides
complete,
concise, and
accurate
information
which is well
organized and
easy to
understand.
1
6
1
6
1
Score
SOAP NOTE RUBRIC
General survey (Describe the state of the patient at the time of the
examination)
Vital signs, wt., BMI
Physical exam-systematic, organized and thorough and related
to the reason of the visit
Diagnosis/ Differentials Diagnosis (10 points)
Diagnosis/(Assessment)
List of differentials supported by S+O findings (5 points)
Must provide 3 differential diagnoses with one citation for
each diagnosis.
Plan of care (10 Points)
10
10
negative
information
(e.g., patient
denies)
8
10
20
10
20
8
18
6
16
Main
diagnosis/
Differentials
Diagnosis is
supported by
the objective
and subjective
assessment
and rationale
for choosing
the diagnosis
is supported
by the
evidence
Main
diagnosis/
Differentials
Diagnosis is
supported by
the objective
and subjective
assessment
but the
rationale for
choosing the
diagnosis is
not supported
by the
evidence
5
5
3
3
Main
diagnosis/
Differentials
Diagnosis is
not supported
by the
objective and
subjective
assessment
and the
rationale for
choosing the
diagnosis is
not supported
by the
evidence
1
1
Complete and
appropriate
plan for the
main problem
and other
active
problems.
Includes
pharmacologic
and/or non-
Mostly
complete and
appropriate
plan for the
main problem
and other
active
problems. May
be missing
appropriate
5
5
6
Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.
SOAP NOTE RUBRIC
pharmacologic
and/or
complete sig
components.
Diagnostic tests/therapies/medications
Follow-up/Pt. Education and Health Promotion
References (5 Points)
5
5
5
5
Provides a
complete and
appropriate
list of
references
that are in
APA format.
References
Total
5
100
5
Comment:
nonpharmacologic
treatments
and/or sig
components.
3
3
References
listed are
appropriate
(i.e. guidelines
or primary),
but not
complete and
some may be
missing. Not
APA
formatted.
3
1
1
References
missing or
very limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.
1
SOAP NOTE
Patient Initials:
Date:
Allergies:
SUBJECTIVE
CC:
Pt. Encounter Number:
Age:
Sex:
Advanced Directives:
HPI: Describe the course of the patient’s illness:
Onset:
Location:
Duration:
Characteristics:
Aggravating Factors:
Relieving Factors:
Treatment:
Current Medications:
PMH
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries:
Family History:
Social History:
ROS
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
SOAP NOTE
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE
Weight
BMI
Height
PHYSICAL EXAMINATION
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests
Temp
Pulse
BP
Resp
SOAP NOTE
Special Tests
Diagnosis
•
Primary Diagnosis▪ Evidence for primary diagnosis should be documented in your Subjective and
Objective exams.
o
Differential Diagnoses- Include three diagnoses
PLAN including education
o Plan:
▪ Further testing
▪ Medication
▪ Education
▪ Non-medication treatments
▪ Referrals
▪ Follow-up visits
References
Pt Initials: WL
Date: 10/05/20
Pt Encounter No.
Age: 59
Allergies: Denies
Sex: F
Advanced Directives: Full Code
“I have numbness on my right index and middle fingers.”
Patient is 59 -year-old female with no PMHx comes to the clinic today c/o numbness to the
right index and middle fingers for the past 2 months. Patient reports right wrist fracture two
years ago. Patient states it is usually a feeling of “pins and needles” sensation, the symptoms
often appear with some activities like while holding a steering wheel, phone or newspaper,
and she is complaining of wake up from sleep so frequent and she need to “shake out” their
hands to try to relieve their symptoms.
Onset: two months ago
Location: right index and middle fingers
Duration: intermittent
Characteristics: sharp
Aggravating Factors: extensive hand work
Relieving Factors: rest
Treatment: None
Current Medications:
B-Complex Tablets
Medication Intolerances: Denies
Chronic Illnesses/Major traumas: Denies
Screening Hx/Immunizations Hx: Up to date. Refused Influenza Vaccine last year.
Mammography (None). Pap smear (2018) normal results. Colonoscopy (at age 50) normal
results.
Hospitalizations/Surgeries: Appendectomy.
Family History
Father- 91 years old alive, HTN and CHF.
Mother-86 years old died from hemorrhagic stroke
Social History
WL is an accountant that works at office. She denies cigarette smoking and been exposed to
cigarette at home, reports a cup of coffee daily at the morning. Patient denies alcohol
consumption and recreational drugs. Patient states not been sexually active.
General
Denies chills, night sweats, fatigue, or recent
weight changes.
Cardiovascular
Denies palpitations, claudication, chest
pain, or orthopnea.
Skin
Denies skin rash, no wound, no change on skin
color or texture, no change in a mole, no
unusual growth, no dry skin, no itching, no
jaundice.
Eyes
Denies visual loss, double vision, or blurred
vision. Patient states has no history or cataracts
or glaucoma.
Ears
Denies ear pain, ear infections, or tinnitus.
Denies hearing loss.
Respiratory
Denies painful breathing, SOB, abnormal
sputum production, cough. Denies recall
taking a TB skin test,
Nose/ Mouth/ Throat
Denies nasal pain or discharge, congestion, or
other sinus problem. Refutes throat swelling or
pain.
Musculoskeletal
Denies limits to ROM, swelling, muscle
pain, or warm joints. Occasional right wrist
pain.
Breast
Denies discharge, redness, tenderness or any
other breast changes. No palpable mass during
self-exam.
Neurological
Patient denies rebuts coordination
difficulties, paralysis, tremors, seizures, or
syncope. Intermittent numbness of the right
index and middle fingers.
Hemo/ Lymph/ Endo
Foregone
Psychiatric
Denies problems with coordination,
nervousness, feelings of irritability, mood
changes, anxiety, or depressive symptoms.
Weight: 84kg
Pulse: 80
Height: 5’6’’
Resp: 16
BMI: 29.9
GI
Patient denies abdominal pain, difficulty
swallowing, vomiting, intolerance to food,
appetite changes, or stool changes.
GU/ Gynecological
Patient denies urinary urgency, frequency,
dysuria, odorous urine and suprapubic pain.
Patient reports voiding at 0900AM
LMP: 10 years ago
Temp: 97.7
Pulse Ox: 100%
BP: 120/80
General Appearance
Well nourished, developed and dressed/groomed, pleasant demeanor, speech clear. Appears to
be without discomfort, does not look distressed. Pain level: 0/10. Normal general appearance.
Patient is awake, oriented, and alert. Well-developed and nourished. Patient keeps a normal
position and posture without deformities. Patient speaks clear and appropriate in native
language. Excellent personal hygiene. No acute distress.
Skin
Skin warm, wnl color and moist. Normal skin turgor. No lesions, redness, swelling or cyanosis
noticed. Capillary refill less than 3 sec.
HEENT
Head Normocephalic with normal hair distribution. No facial swelling noted. Eyes: PERRLA;
EOMI. Fundi benign. Ears: TMs intact with no erythema; Nose: Mucous membranes pink and
moist. Nasopharynx without erythema, exudates, or lesions; Mouth: good dentition, no
missing teeth, tongue in normal position, Gag Reflex intact.
Cardiovascular
S1 and S2 normal without MRG. No extra murmurs or sound present. No carotid bruits. No
JVD.
Respiratory
Symmetric chest wall. Respirations even and unlabored; lungs clear to auscultation bilaterally.
No fremitus.
Gastrointestinal
Abdomen soft, no tenderness, no masses, Bowel sounds presents and normal in the four
quadrants. No abnormal aortic pulsations. No ascites. No splenomegaly, no hepatomegaly, nor
hernia. No muscle rigidity. No rebound, no guarding. No painful to palpation.
Breast
No nipple retraction, lymphadenopathy, or nipple discharge. No changes in the breast area
skin.
Genitourinary
No inguinal hernias or CVA tenderness.
Musculoskeletal
ROM WNL without crepitus or pain except in Left Upper Arm ROM limited due to pain
Neurological
Patient AAOX4. Speech clear and coherent. Cranial nerves I-XII intact. Motor and sensory
levels intact. Tinel’s Sign and Phalen’s Maneuver positive.
Psychiatric
Patient appears to have normal affect and is able to follow commands. No signs of anxiety or
depression noticed.
Labs Tests
None
Special Tests
Cervical X-ray
Right hand X-ray
Nerve Conduction Velocity Test, Electromyogram
Diagnosis
Differential Diagnosis
Carpal Tunnel Syndrome (ICD 10 G56.01).
– Cervical Radiculopathy
– Brachial plexopathies
– Posttraumatic Medial Nerve Damage
Pharmacological treatment:
• Ibuprofen 800mg po bd.
• Gabapentin 100 mg po tid
Non-Pharmacologic treatment:
• Wrist splint
Teaching
– The patient was instructed in carpal tunnel syndrome to avoid activities that increase
stress on inflamed tissues, grasping and gripping action of hand and wrist, to keep the
wrist in neutral position, to avoid the wrist in a bent flexed, twisted, turned position,
and to minimize repetitive movements, including holding an object for extended
periods of time.
– The patient was advised to wear a wrist splint to help keep the wrist in neutral position.
– The patient was taught on range-of-motion exercises and their importance for strengths
of muscles.
References
1. Alcan, V., Zinnuroğlu, M., Karataş, G. K., & Bodofsky, E. (2018). Comparison of
Interpolation Methods in the Diagnosis of Carpal Tunnel Syndrome. Balkan Medical
Journal, 35(5), 378–383. https://doi.org/10.4274/balkanmedj.2017.1314.
2. 2-Durham, C. O., & VanRavenstein, K. (2017). It’s All in the Wrist: Diagnosis and
Management of Carpal Tunnel Syndrome. Orthopaedic Nursing, 36(5), 323–329.
https://doi.org/10.1097/NOR.0000000000000390.
3. 3-Fernández, de‐las‐Peñas, C., de, la‐Llave‐Rincón, A. I., Cescon, C., Barbero, M.,
Arias, B. J. L., & Falla, D. (2019). Influence of Clinical, Psychological, and
Psychophysical Variables on Long‐term Treatment Outcomes in Carpal Tunnel
Syndrome: Evidence from a Randomized Clinical Trial. Pain Practice, 19(6), 644–655.
https://doi.org/10.1111/papr.12788.
4. Publication Manual of the American Psychological Association, 6th Edition (2009)
5. Dr. Allan H. Goroll MD MACP; Dr. Albert G. Mulley Jr. MD MPP. (2014). Primary
Care Medicine: Office Evaluation and Management of the Adult Patient. 7th Ed.
6. Lucille A. Joel EdD APN FAAN. (2017). Advanced Practice Nursing: Essentials for
Role Development.
Subjective
Chief Complain
History of Present Illness
Review of System
Physical Exam
Plan
SOAP NOTE
Patient Initials:
Date:
Allergies:
SUBJECTIVE
CC:
Pt. Encounter Number:
Age:
Sex:
Advanced Directives:
HPI: Describe the course of the patient’s illness:
Onset:
Location:
Duration:
Characteristics:
Aggravating Factors:
Relieving Factors:
Treatment:
Current Medications:
PMH
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries:
Family History:
Social History:
ROS
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
SOAP NOTE
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE
Weight
BMI
Height
PHYSICAL EXAMINATION
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests
Temp
Pulse
BP
Resp
SOAP NOTE
Special Tests
Diagnosis
•
Primary Diagnosis▪ Evidence for primary diagnosis should be documented in your Subjective and
Objective exams.
o
Differential Diagnoses- Include three diagnoses
PLAN including education
o Plan:
▪ Further testing
▪ Medication
▪ Education
▪ Non-medication treatments
▪ Referrals
▪ Follow-up visits
References
SOAP notes
Yolexis Alonso
Advanced Health Assessment-DBX-DL01
Prof. Jose M Carralero
Due weeks 4 and 5
Cc: Pain and numbness to right index and middle fingers.
HPI: WL is a 59 years old female patient with past medical Hx of right wrist fracture two
years ago, without medication allergies or intolerance. Patient has been working in an office setting
for several years. Now the patient complains of Sharp, intermittent, pain with numbness to right
index and middle fingers for the past 2 months. Patient states it is usually a feeling of “pins and
needles” sensation, the symptoms often appear with some activities like while holding a steering
wheel, phone, or newspaper, symptoms intensify with extensive hand work and relieve with rest.
No medical treatment has been taken so far.
ROS: Denies chills, night sweats, fatigue, or recent weight changes. No skin rash, no
wound, no change on skin color or texture, no unusual growth, no dry skin, no itching, no jaundice.
No palpitations, claudication, chest pain, or orthopnea. No painful breathing, SOB, abnormal
sputum production, cough. No visual loss, double vision, or blurred vision. Denies abdominal
pain, difficulty swallowing, vomiting, intolerance to food, appetite changes, or stool changes. No
ear pain, infections, or tinnitus, nor hearing loss. Patient denies urinary urgency, frequency,
dysuria, odorous urine, or suprapubic pain. Denies nasal pain or discharge, congestion, or other
sinus problem. No throat swelling or pain. Denies limits to ROM, swelling, muscle pain, or warm
joints. Occasional right wrist pain. Denies discharge, redness, tenderness, or any other breast
changes. No palpable mass during self-exam. Patient denies rebuts coordination difficulties,
paralysis, tremors, seizures, or syncope. Intermittent numbness of the right index and middle
fingers. Denies problems with coordination, nervousness, feelings of irritability, mood changes,
anxiety, depression or any other symptom.
PE: Normal general appearance. Patient is awake, oriented, and alert. Patient keeps a
normal position and posture without deformities. Patient speaks clearly and appropriately in native
language, pleasant demeanor, excellent personal hygiene well-dressed/groomed. Appears to be
without discomfort, does not look distressed. Well-developed and nourished. Pain level: 0/10.
Vital signs WNL (Weight: 84kg, Height: 5’6’’ , BMI: 29.9, Temp: 97.7, BP: 120/80, Pulse: 80,
Resp: 16, Pulse Ox: 100%. Skin normal color, no lesions, redness, swelling, or cyanosis noticed.
Warm, and moist with normal skin turgor. Capillary refill less than 3 sec. Head Normocephalic
with normal hair distribution. No facial swelling noted. Pupils are equal, round, and reactive to
light and accommodation (PERRLA). Extraocular Movements Intact. Fundi benign. No Jugular
Venous Distention, no carotid bruits. Heart sounds with S1 and S2 normal no murmurs, Rubs, or
Gallops present. Symmetric chest wall, respirations even and unlabored; lungs clear to auscultation
bilaterally, no fremitus. Abdomen: No visible mass. Bowel sounds presents and normal in the
four quadrants. Soft, no tenderness or pain to palpation, no palpable masses or hernia, no abnormal
aortic pulsations. No ascites, splenomegaly, or hepatomegaly. No rebound tenderness or guarding.
Normal range of movement without crepitus or pain except in Left Upper Arm where ROM limited
due to pain. Patient Awake, Alert, and Oriented to Date, Place, Person, and Situation. Speech clear
and coherent. Cranial nerves I-XII intact. Motor and sensory levels intact. Tinel’s Sign and
Phalen’s Maneuver positive.
Special Tests: Cervical X-ray, Right hand X-ray, Nerve Conduction Velocity Test,
Electromyogram.
Diagnosis: Carpal Tunnel Syndrome (ICD 10 G56.01).
Differential Diagnosis:
–
Cervical radiculopathy involves nerve inflammation in the neck resulting from
compression or irritation of nerve roots as they exit the spine in the neck. Symptoms can be
like those in CTS causing dull pain, tingling, and weakness in the hand with occasional
shooting pains along the nerve path. This condition can be associated to herniated or
degenerated discs, cervical stenosis, or cervical osteoarthritis that can trigger nerve
impingement in the cervical spine, these nerves innervate similar areas of the hand as the
median nerve, that’s why a comprehensive neurological evaluation, electrodiagnostic testing
(EMG), and possibly neck imaging help differentiate between CTS and cervical radiculopathy.
–
Brachial plexopathies refer to injuries affecting the brachial plexus, a network of nerves
extending from the cervical spinal cord to the axilla (armpit). signs and symptoms of brachial
plexopathies, which are injuries affecting the brachial plexus, a network of nerves responsible
for transmitting signals from the spinal cord to the shoulder, arm, and hand. When injured the
patient complains of electric shock or burning sensation shooting down the arm. Numbness
and weakness in the arm. These symptoms usually last only a few seconds or minutes, but in
some cases, they may linger for days or longer. In more-Severe Injuries the patient complains
of weakness or inability to use certain muscles in the hand, arm, or shoulder, complete lack of
movement and feeling in the arm, including the shoulder and hand, severe pain, neck pain, and
those symptoms can be in one or both arms and again, clinical assessment and patient history
may not be enough to stablish a diagnosis so complementary tests such as electromyography
(EMG) is needed.
–
Posttraumatic Medial Nerve Damage occurs due to trauma or injury to the median nerve,
symptoms have rapid onset usually developing immediately after trauma, severe pain, patients
may experience more intense symptoms, including pain, urgent surgical release may be
necessary in severe cases.
Plan: Patient instructed in carpal tunnel syndrome to avoid activities that increase stress
on inflamed tissues, grasping and gripping action of hand and wrist, to keep the wrist in neutral
position, to avoid the wrist in a bent flexed, twisted, turned position, and to minimize repetitive
movements, including holding an object for extended periods of time. Patient advised to wear a
wrist splint to help keep the wrist in neutral position, range-of-motion exercises recommended as
well as their importance for strengths of muscles.
Rx: Ibuprofen 800mg po BID; Gabapentin 100 mg po TID; Wrist splint.
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