Description
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
Instructions:Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
Unformatted Attachment Preview
Distinguised
Excellent
Fair
Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
3 Points
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
2 Points
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender)
Information is completely missing
2 Points
1.5 Points
1 Points
0 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)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points
3 Points
2 Points
0 Points
If allergies are present, students lists only the
type of allergy name
Information is completely missing
1 Points
0 Points
Subjective
Chief Complaint (Reason for seeking
health care)
Demographics
History of the Present Illness (HPI)
Allergies
Includes NKA (including = Drug,
If allergies are present, students lists type Drug,
Environemental, Food, Herbal, and/or Latex
environemtal factor, herbal, food, latex name and
or if allergies are present (reports for each
includes severity of allergy OR description of
severity of allergy AND description of
allergy
allergy)
2 Points
Review of Systems (ROS)
1.5 Points
Includes 3 or fewer assessments for each body
Includes 3 or fewer assessments for each body
Includes a minimum of 3 assessments for
each body system and assesses at least 9 system and assesses 5-8 body systems directed to system and assesses less than 5 body systems
chief complaint AND uses the words “admits” directed to chief complaint OR student does not
body systems directed to chief complaint
use the words “admits” and “denies”
and “denies”
AND uses the words “admits” and “denies”
12 Points
6 Points
3 Points
0 Points
Information is completely missing
0 Points
Objective
Vital Signs
Includes all 8 vital signs, (BP (with patient
Includes 7 vital signs, (BP (with patient position), Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with
HR, RR, temperature (with Fahrenheit or Celsius position), HR, RR, temperature (with Fahrenheit
Fahrenheit or Celsius and route of
and route of temperature collection), weight,
or Celsius and route of temperature collection), Information is completely missing
temperature collection), weight, height, BMI
height, BMI (or percentiles for pediatric
weight, height, BMI (or percentiles for pediatric
(or percentiles for pediatric population) and
population) and pain.)
population) and pain.)
pain.)
2 Points
Labs
Medications
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
3 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
1.5 Points
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
1 Points
0 Points
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
Information is completely missing
highlight abnormal values.
2 Points
1 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency)
0 Points
Information is completely missing
Screenings
Past Medical History
4 Points
Includes an assessment of at least 5
screening tests
2 Points
Includes an assessment of at least 4 screening
tests
3 Points
2 Points
Includes (Major/Chronic, Trauma,
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis either year of diagnosis OR whether the diagnosis
is active or current
is active or current
3 Points
Past Surgical History
Family History
Social History
0 Points
Information is completely missing
1 Points
0 Points
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current
Information is completely missing
1 Points
0 Points
Includes, for each surgical procedure, the
Includes, for each surgical procedure, the year of Includes, for each surgical procedure but not the
year of procedure and the indication for the
procedure OR indication of the procedure
year of procedure or indication of the procedure Information is completely missing
procedure
3 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
3 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
3 Points
Physical Examination
2 Points
1 Points
Includes an assessment of at least 3 screening
tests
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
12 Points
2 Points
1 Points
0 Points
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
2 Points
1 Points
0 Points
Includes 10 of the 11 following: tobacco use,
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
status, current/previous occupation, sexual
Information is completely missing
orientation, sexually active, contraceptive use,
orientation, sexually active, contraceptive use,
and living situation.
and living situation.
2 Points
1 Points
0 Points
Includes a minimum of 3 assessments for each
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems body system and assesses at least 4 body systems Information is completely missing
directed to chief complaint
directed to chief complaint
6 Points
3 Points
0 Points
Assessment
Diagnosis
Includes a clear outline of the accurate
Includes a clear outline of the accurate diagnoses
principal diagnosis AND lists the remaining
Includes an inaccurate diagnosis as the principal
addressed at the visit but does not list the
Information is completely missing
diagnoses addressed at the visit (in
diagnosis
diagnoses in descending order of priority
descending priority)
5 Points
Differential Diagnosis
3 Points
2 Points
0 Points
Includes at least 3 differential diagnoses for Includes 2 differential diagnoses for the principal Includes 1 differential diagnosis for the principal
Information is completely missing
the principal diagnosis
diagnosis
diagnosis
5 Points
3 Points
Plan
2 Points
0 Points
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Includes a detailed pharmacologic treatment
Includes a detailed pharmacologic treatment plan
Includes a detailed pharmacologic treatment plan
plan for each of the diagnoses listed under
for each of the diagnoses listed under
for each of the diagnoses listed under
“assessment”. The plan includes ALL of
“assessment”. The plan includes less than 4 of
“assessment”. The plan includes 4 of the
the following: drug name, dose, route,
the following: the drug name, dose, route,
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
frequency, duration and cost as well as
frequency, duration and cost as well as education
education related to pharmacologic agent. If
related to pharmacologic agent. If the diagnosis
related to pharmacologic agent. If the diagnosis is
the diagnosis is a chronic problem, student
is a chronic problem, student includes
a chronic problem, student includes instructions
includes instructions on currently prescribed
instructions on currently prescribed medications
on currently prescribed medications as above.
medications as above.
as above.
Information is completely missing
5 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
5 Points
3 Points
2 Points
0 Points
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time.
Information is completely missing
3 Points
2 Points
0 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.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points
3 Points
2 Points
0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
4 Points
2 Points
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
2 Points
1 Points
0 Points
Does not include follow up plan
0 Points
0 Points
Moderate level of APA precision
Incorrect APA style
Information is completely missing
3 Points
2 Points
1 Points
0 Points
Free of grammar and spelling errors
Writing mechanics need more precision and
attention to detail
Writing mechanics need serious attention
3 Points
2 Points
0 Points
Writing
References
Grammar
High level of APA precision
0 Points
SOAP Note 1
Encounter date: January 8th, 2024
Patient Initials: __G.K._ Gender: M/F/Transgender __F_ Age: _5_ Race: W Ethnicity _W__
Reason for Seeking Health Care: Cough and runny nose for six days.
HPI:_ The child’s mother states the patient started with a slight cough six days ago, accompanied
by a runny nose. The mother reported that the child had a mild fever of 38.1 Celsius. She
administered Children’s Tylenol Oral Suspension to the child. It helps alleviate the fever. There
has been an increase in irritability in the child during the past few days, especially at night. The
mother also reported a reduced appetite and coughing up yellow phlegm, mostly congested at
night. She tried OTC Vicks vapor rub and a humidifier. Denies any diarrhea or vomiting. Besides
congestion and a runny nose, the mother denies suffering from other symptoms, including cough
and ear pain. The mother states that she is up-to-date on all immunizations. She is concerned that
the child may have contracted the flu from the daycare facility.
Allergies(Drug/Food/Latex/Environmental/Herbal): NKA
Current perception of Health:
Excellent
Good
Fair Poor
Past Medical History
• Major/Chronic Illnesses: Asthma
• Trauma/Injury: None
• Hospitalizations : None
•
Past Surgical History: None
Medications: _Children’s Tylenol , Vicks Vapor Rub, Albuterol Nebulizer
Copyright © MVJ 2018
Family History: Father: Alive, at age 35 years old; Mother: Iron deficiency Anemia, age 34
years old; Maternal grandmother; Passed away from breast cancer at 56 years old; Paternal
grandfather; passed away from Colorectal Cancer at age 64 years old.
Social history:
Lives: Single-family House/Condo/ with stairs: Single-family house
Family Composition: Family/Mother/Father/Alone: Mother, Father, and older sister
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc: Lead screen
negative at age 24 months.
Exposures: Sun
Immunization HX: Up to date per Mother
Review of Systems:
General: Quiet affect.
HEENT: Denies eye pain, discharge, excessive tearing, or itchiness. -Ears: No problems with
hearing. Mother admits to throat pain
Neck: Cervical Lymph nodes swollen
Lungs: Clear. No audible wheezing
Cardiovascular: No syncope or palpations
GI: Denies constipation or diarrhea
GU: No dysuria noted
Neuro: AOX 3
Copyright © MVJ 2018
Musculoskeletal: Denies of any weakness
Derm: Mother denies any skin changes
Nutrition: Decrease in appetite
Sleep/Rest: Not enough rest due to coughing spells
Physical Exam
BP: 85/52 Right arm
TPR 37.9 C Oral
HR: _100 RR: _30 __Ht. _ 42.12 inch Wt. 40.2 lbs__ BMI (percentile) _15.9____
General: Appears irritable and ill
HEENT: No visible lesions or rashes. Ears are erythematous and bulging bilaterally and
immobile. The nasal mucosa is dry and mildly erythematous.
Neck: Anterior Cervical swollen lymph nodes
Pulmonary: Wheezing noted. No rhonchi or crackles. No accessory muscle use.
Cardiovascular: no murmurs or gallops.
GI: Bowel sounds are present. Abdomen non-tender and non-distended
GU: No hematuria or dysuria.
Neuro: Aox 3. Age appropriate , Mother answers all the questions
Musculoskeletal: No edema noted. Full range of motion noted in all extremities
Copyright © MVJ 2018
Derm: No visible lesions or rashes. Skin appropriate for ethnicity
Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
3.
Principal Diagnoses
1.
2.
Plan
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Copyright © MVJ 2018
Follow-up:
Anticipatory Guidance:
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
Copyright © MVJ 2018
DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
Copyright © MVJ 2018
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