NUR 612 Clinical SOAP Note 3

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

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 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:____________________________________________________________

Demographics

1 to >0.8 pts

Begins with patient initials, age, race, ethnicity and gender (5 demographics)

Chief Complaint (Reason for seeking health care)

4 to >3 pts

Includes a direct quote from patient about presenting problem

History of the Present Illness (HPI)

5 to >3 pts

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

Allergies

2 to >1.5 pts

Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)

Review of Systems (ROS)

2 to >1.5 pts

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.

Labs

4 to >2 pts

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)

Past Medical History

3 to >2 pts

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current

Past Surgical History

3 to >2 pts

Includes, for each surgical procedure, the year of procedure and the indication for the procedure

Family History

3 to >2 pts

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

Social History

3 to >2 pts

Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation

Health Maintenance / Screenings

3 to >2 pts

Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests

Physical Examination

15 to >8 pts

Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint

Diagnosis

5 to >3 pts

Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)

Differential Diagnosis

5 to >3 pts

Includes at least 3 differential diagnoses for the principal diagnosis

Pharmacologic treatment plan

5 to >3 pts

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required 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.

Diagnostic / Lab Testing

3 to >2 pts

Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”

Education

3 to >2 pts

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

Anticipatory Guidance

3 to >2 pts

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))

Follow Up Plan

2 to >1 pts

Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)

Prescription

3 to >2 pts

Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials

Writing Mechanics, Citations, and APA Style

3 to >2 pts

Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors.