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Week 4: Problem-Focused SOAP Note

Problem-Focused SOAP Note Format

Demographic Data

• Patient initial (one initial only), age, and gender must be HIPAA compliant.

Subjective

• Chief Complaint (CC)

• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset,

Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors,

Treatment)

• Past Med. Hx (PMH) : Medical or surgical problems, hospitalizations, medications,

allergies, iImmunizations , and preventative health maintenance

• Family Hx

• 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

• Physical findings listed by body systems, not paragraph form

Assessment (the diagnosis)

• Three (3) differential diagnosis (if applicable) with rationale

• Final diagnosis with rationale and pathophysiological explanation

Plan

• Dx Plan (lab, x-ray)

• Tx Plan ( meds )

• Pt. Education, including specific medication teaching points

• Referral/Follow-up

• Health maintenance (including when screenings, immunizations, etc., are next due):

Reference

• Compare care given to the patient with the National Standards of Care/National

Guidelines. Cite accordingly.

Rubric NURS_663L-A_DE - SOAP Note Rubric

NURS_663L-A_DE - SOAP Note Rubric

Criteria Ratings Pts

This criterion is linked to a Learning Outcome S (Subject)

7.5 to >6.9 pts Accomplished Symptom 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.

7.5 pts

This criterion is linked to a Learning Outcome O (Object) 7.5 to >6.9 pts

Accomplished Complete, 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.

7.5 pts

This criterion is linked to a Learning Outcome A (DDX)

7.5 to >6.9 pts Accomplished Diagnosis and differential dx are correct with ICD code and supported by subjective and objective data.

7.5 pts

This criterion is linked to a Learning Outcome P (Plan)

7.5 to >6.9 pts Accomplished Plan 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).

7.5 pts

Total Points: 30