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SOAP Note Clinical Documentation

Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

Each SOAP note carries a 30-point value.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.

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