Description
Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.
45 y/o female presents to clinic with UTI. Prescribed ciprofloxacin 500mg tab po BID x 14 days. Please fill in each tab according related to this diagnosis.
Review the rubric for more information on how your assignment will be graded.
Demographic Data
Age, and gender (must be HIPAA compliant)
Subjective
Chief Complaint (CC) unless an Annual Physical Exam (APE)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Vital signs
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply for this visit
Plan
Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
Subjective
6 to >5.4 pts
Accomplished
All subjective data is included (HPI, nutrition, meds, allergies, PMH, FH, SH). Is complete, concise, and relevant with no extraneous data.
5.4 to >4.8 pts
Satisfactory
Most subjective data is included (HPI, nutrition, meds, allergies, PMH, FH, SH). Some extraneous data is present and/or one minor data point missing.
4.8 to >4.2 pts
Needs Improvement
Subjective data is missing. There is too much extraneous data and/or 2-3 major data points missing
4.2 to >0 pts
Unsatisfactory
Subjective data is missing or is not organized. Objective or other data is mixed into the subjective data.
6 pts
This criterion is linked to a Learning OutcomeObjective
6 to >5.4 pts
Accomplished
Complete, concise, well organized, and well written with applicable vital signs. Organized by body system in list format. No extraneous data.
5.4 to >4.8 pts
Satisfactory
All relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format. Includes some but not all applicable vital signs or other required information.
4.8 to >4.2 pts
Needs Improvement
Omitted important relevant exams, vital signs, and/or not in list format.
4.2 to >0 pts
Unsatisfactory
Omitted important relevant exams, vital signs, and/or subjective data are included. Lacking organization.
6 pts
This criterion is linked to a Learning OutcomeAssessment
6 to >5.4 pts
Accomplished
Preventative care or applicable coding of visit and ICD10 is correct and includes additionally applicable preventative diagnoses based on age/population-specific recommendations.
5.4 to >4.8 pts
Satisfactory
Assessment is correct with ICD10 codes; however, some minor additional applicable preventative diagnoses based on age/ population-specific recommendations are missing
4.8 to >4.2 pts
Needs Improvement
Assessment is correct but either does not include ICD10 code or is missing major additional applicable preventative diagnoses based on age/ population-specific recommendations
4.2 to >0 pts
Unsatisfactory
Assessment is not correct or is not provided. Missing applicable preventative diagnoses based on age/population-specific recommendations
6 pts
This criterion is linked to a Learning OutcomePlan
6 to >5.4 pts
Accomplished
Plan is organized, complete and evidence-based according to National Standards of Care. Individualized to the specific patient and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).
5.4 to >4.8 pts
Satisfactory
Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching but may be missing 1-2 minor points
4.8 to >4.2 pts
Needs Improvement
Plan is less organized and not based on evidence according to National Standards of Care. Does not address each diagnosis or may not be individualized to the specific patient. Missing medication teaching or one of the 5 components.
4.2 to >0 pts
Unsatisfactory
No plan is provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching.
6 pts
This criterion is linked to a Learning OutcomeProfessional Documentation, Communication, and Engagement
6 to >5.4 pts
Accomplished
Addresses all instructor /preceptor comments and makes all changes and applies feedback as needed. Maintains a positive attitude toward faculty feedback.
5.4 to >4.8 pts
Satisfactory
Responds to and addresses some instructor / preceptor comments or questions and applies most instructor feedback to work. Maintains a positive attitude toward faculty feedback.
4.8 to >4.2 pts
Needs Improvement
Responds to some instructor / preceptor comments or questions but does not apply that feedback to work. A positive attitude toward faculty feedback needs improvement.
4.2 to >0 pts
Unsatisfactory
Does not respond to any instructor / preceptor comments and questions. Does not address instructor /preceptor comments and does not make the needed changes. Fails to respond and communicate with instructor.
6 pts
Total Points: 30
