SOAP NOTE ABOUT THE HEALTHY ADULTS

Points

Description

5

Demographic.

5

Chief complaint stated in patient’s own words.

10

HPI, PMHx, PSxHx, Family History, Social Habits

10

Subjective: Contains all systems relevant information to make assessment with normal and abnormal findings.

10

Objective present and contains all pertinent objective information available (drug allergies, physical findings, vital signs, drug list, etc)

15

Assessment presents justification for Main or Primary diagnosis/ Articles r/t Dx in references. / ICD 10 codes.

15

Assessment rules out Dx of other potential disorders

5

Plan contains discussion of therapy options with pros and cons of each.

10

Plan stated as directives (start, stop, non-pharmacologic and pharmacologic treatment etc)/ Teaching.

5

Plan include monitoring and follow up

5

Clarity of the Write-up: literate, organized, and complete.

5

SOAP note link to case ID