25 Nov 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 be
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
Complete soap note
Episodic Women’s Health SOAP Note Template
Encounter date:
Patient Initials: Gender: Age: Race/Ethnicity:
Subjective
Reason for Seeking Health Care:
History of Present Illness (HPI):
Allergies (Drug/Food/Latex/Environmental/Herbal):
Current Medications (including over the counter medications):
Past Medical History (PMH):
OB/GYN History:
Past Surgical History:
Family Medical History:
Social History:
Review of Systems (ROS)
Focus on systems affecting women’s health and inquire about systems relevant to the reason for the visit)
Physical Examination
Vital Signs
General Appearance
Include physical exam of all relevant systems based on the reason for the visit and the HPI. Perform a cardiopulmonary exam on all patients regardless of the reason for seeking care.
|
Significant Data/Contributing Dx/Labs/Misc |
Assessment
Differential Diagnoses (3 minimum)
Primary Diagnoses
Plan
For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit.
Include age-appropriate health promotion/maintenance/screening needs.
Remember that for every S (reason for the visit), there must be an O, A, and P (relevant exam, diagnosis, and plan). Always sign your notes.
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: ____________________________________________________________
Signature (with appropriate credentials): __________________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
5
Joseph, M. V. (2021). Episodic Women’s Health SOAP Note. Copyright ©
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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 3 Points 2 Points 0 Points Begins with patient initials, age, race, ethnicity and gender (5 demographics)
Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)
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
Includes NKA (including = Drug, Environemental, Food, Herbal, and/or Latex or if allergies are present (reports for each
severity of allergy AND description of allergy)
If allergies are present, students lists type Drug, environemtal factor, herbal, food, latex name and
includes severity of allergy OR description of allergy
If allergies are present, students lists only the type of allergy name Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint
AND uses the words “admits” and “denies”
Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to
chief complaint AND uses the words “admits” and “denies”
Includes 3 or fewer assessments for each body system and assesses less than 5 body systems
directed to chief complaint OR student does not use the words “admits” and “denies”
Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with
Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and
pain.)
Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius
and route of temperature collection), weight, height, BMI (or percentiles for pediatric
population) and pain.)
Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric
population) and pain.)
Information is completely missing
2 Points 1.5 Points 1 Points 0 Points
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.
Includes a list of the labs reviewed at the visit, values of lab results but does not highlight
abnormal values.
Includes a list of the labs reviewed at the visit but does not include the values of lab results or
highlight abnormal values. Information is completely missing
3 Points 2 Points 1 Points 0 Points Includes a list of all of the patient reported medications and the medical diagnosis for
the medication (including name, dose, route, frequency)
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) Information is completely missing
Subjective
Objective
Medications
Labs
Review of Systems (ROS)
History of the Present Illness (HPI)
Demographics
Chief Complaint (Reason for seeking health care)
Allergies
Vital Signs
4 Points 2 Points 1 Points 0 Points Includes an assessment of at least 5
screening tests Includes an assessment of at least 4 screening
tests Includes an assessment of at least 3 screening
tests Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes (Major/Chronic, Trauma, Hospitaliztions), for each medical diagnosis, year of diagnosis and whether the diagnosis
is active or current
Includes (Major/Chronic, Trauma, Hospitaliztions), for each medical diagnosis,
either year of diagnosis OR whether the diagnosis is active or current
Includes each medical diagnosis but does not include year of diagnosis or whether the
diagnosis is active or current Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes, for each surgical procedure, the year of procedure and the indication for the
procedure
Includes, for each surgical procedure, the year of procedure OR indication of the procedure
Includes, for each surgical procedure but not the year of procedure or indication of the procedure Information is completely missing
3 Points 2 Points 1 Points 0 Points Includes an assessment of at least 4 family members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
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
3 Points 2 Points 1 Points 0 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.
Includes 10 of the 11 following: tobacco use, drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual orientation, sexually active, contraceptive use,
and living situation.
Includes 9 or less 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.
Information is completely missing
3 Points 2 Points 1 Points 0 Points
Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems
directed to chief complaint
Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems
directed to chief complaint Information is completely missing
12 Points 6 Points 3 Points 0 Points
Includes a clear outline of the accurate principal diagnosis AND lists the remaining
diagnoses addressed at the visit (in descending priority)
Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority
Includes an inaccurate diagnosis as the principal diagnosis Information is completely missing
5 Points 3 Points 2 Points 0 Points
Includes at least 3 differential diagnoses for the principal diagnosis
Includes 2 differential diagnoses for the principal diagnosis
Includes 1 differential diagnosis for the principal diagnosis
Information is completely missing
5 Points 3 Points 2 Points 0 Points
Diagnosis
Assessment
Plan
Family History
Screenings
Past Medical History
Differential Diagnosis
Social History
Past Surgical History
Physical Examination
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of
the following: drug name, dose, route, frequency, duration and cost as well as
education related to pharmacologic agent. If the diagnosis is a chronic problem, student
includes instructions on currently prescribed medications as above.
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under
“assessment”. The plan includes 4 of the following 7: the drug name, dose, route,
frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under
“assessment”. The plan includes less than 4 of the following: the drug name, dose, route,
frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis
is a chronic problem, student includes instructions on currently prescribed medications
as above.
Information is completely missing
5 Points 3 Points 2 Points 0 Points Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no
diagnostic testing clinically required at this time”
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
5 Points 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 2 Points 1 Points 0 Points Includes recommendation for follow up,
including time frame (i.e. x # of days/weeks/months)
Includes recommendation for follow up, but does not include time frame (i.e. x # of
days/weeks/months) Does not include follow up plan
4 Points 2 Points 0 Points 0 Points
High level of APA precision 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 0 Points
Pharmacologic treatment plan
Follow up plan
Writing
Grammar
References
Diagnostic/Lab Testing
Anticipatory Guidance
Education
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