Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints
45 y/o male presents to clinic complaining of left knee pain.
Dx: OA of left knee
Use the format below for your SOAP note.
Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.
Problem-focused SOAP Note Format
Demographic Data
- Age, and gender (must be HIPAA compliant)
Subjective
- Chief Complaint (CC): A short statement about why they are there
History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym 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
- Family Hx: any history of CA, DM, HTN, MI, CVA?
- 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- Highlight abnormal findings
Assessment (the diagnosis)
- At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
Plan
- Dx Plan (lab, x-ray)
- Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
- Pt. Education, including specific medication teaching points
Referral/Follow-up
- Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due
Reference
- Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
Rubric
Problem-focused SOAP Note (1)
| Criteria | Ratings | Pts | |||
|---|---|---|---|---|---|
|
This criterion is linked to a Learning OutcomeSubjective |
15 to >13.8 ptsAccomplishedSymptom analysis is well organized, with C/C, OLDCART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, relevant with no extraneous data.13.8 to >12.6 ptsSatisfactorySymptom analysis well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Some extraneous data present and/or one minor data point missing.12.6 to >10.2 ptsNeeds ImprovementSymptom analysis is not well organized. Data is missing. There is too much extraneous data and/or 2-3 minor data points missing.10.2 to >0 ptsUnsatisfactorySymptom analysis is inadequate, is not organized. Objective or other data is mixed into the subjective data. Important data is missing. |
15 pts |
|||
|
This criterion is linked to a Learning OutcomeObjective |
15 to >13.8 ptsAccomplishedComplete, concise, well organized and well written and includes pertinent positive and pertinent negative physical findings. Organized by body system in list format. No extraneous data.13.8 to >12.6 ptsSatisfactoryAll relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format.12.6 to >10.2 ptsNeeds ImprovementOmitted important relevant exams and/or not in list format.10.2 to >0 ptsUnsatisfactoryOmitted important relevant exams and/or subjective data are included. Lacking organization. | ||||
|
This criterion is linked to a Learning OutcomeAssessment |
15 to >13.8 ptsAccomplishedDiagnosis and differential dx are correct with ICD code and supported by subjective and objective data.13.8 to >12.6 ptsSatisfactoryDiagnosis is correct with ICD codes and is supported by subjective and objective data, however the most accurate differential diagnosis not listed according to subjective and objective data.12.6 to >10.2 ptsNeeds ImprovementDiagnosis is correct but either does not include ICD code or is missing two or more important differential diagnoses according to the subjective and objective data provided.10.2 to >0 ptsUnsatisfactoryDiagnosis is not correct, is not provided or is not reflective of the subjective and objective data provided. | ||||
|
This criterion is linked to a Learning OutcomePlan |
15 to >13.8 ptsAccomplishedPlan 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 and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).13.8 to >12.6 ptsSatisfactoryPlan 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.12.6 to >10.2 ptsNeeds ImprovementPlan 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.10.2 to >0 ptsUnsatisfactoryNo Plan provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching. | ||||
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Total Points: 60 |
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