Y-SOAP

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of pa8ents. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Iden2fying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The pa8ent complaint should be given in quotes. If the pa8ent has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjec8ve and under the appropriate number.

2) Subjec2ve Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Loca8on, quality , quan8ty or severity, 8ming, seMng, factors that make it beNer or worse, and associate manifesta8ons.(10pts).

b) Review of systems of associated systems, repor8ng all per8nent posi8ves and nega8ves (10pts).

c) Any PMH, family hx, social hx, allergies, medica8ons related to the complaint/problem (10pts). If more than one chief complaint, each should be wriNen u in this manner.

3) Objec2ve Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those iden8fied in 2b.(10pts).

b) Per8nent posi8ves and nega8ves must be documented for each relevant system.

c) Any abnormali8es must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, posi8ve/ nega8ve, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this sec8on divided into separate numbered sec8ons.

6) Subjec2ve/ Objec2ve, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differen8al diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjec8ve sec8on and then the assessment and plan. The management should be consistent with the assessment/ diagnoses iden8fied.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

Guidelines for Focused SOAP Notes · Label each sec2on of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbrevia2ons

S: SUBJECTIVE DATA (informa2on the pa2ent/caregiver tells you).

Chief Complaint (CC): a statement describing the pa8ent’s symptoms, problems, condi8on, diagnosis, physician-recommended return(s) for this pa8ent visit. The pa8ent’s own words should be in quotes.

History of present illness (HPI): a chronological descrip8on of the development of the pa8ent's chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Loca8on, Dura8on, Characteris8cs, Aggrava8ng Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last pa8ent encounter.

Past Medical History (PMH): Update current medica8ons, allergies, prior illnesses and injuries, opera8ons and hospitaliza8ons allergies, age-appropriate immuniza8on status.

Family History (FH): Update significant medical informa8on about the pa8ent's family (parents, siblings, and children). Include specific diseases related to problems iden8fied in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant ac8vi8es that may include informa8on such as marital status, living arrangements, occupa8on, history of use of drugs, alcohol or tobacco, extent of educa8on and sexual history.

Review of Systems (ROS). There are 14 systems for review. List posi8ve findings and per8nent nega8ves in systems directly related to the systems iden8fied in the CC and symptoms which have occurred since last visit; (1) cons8tu8onal symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointes8nal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lympha8c, {14) allergic/immunologic. The ROS should mirror the PE findings sec8on.

0: OBJECTIVE DATA (informa2on you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and pa8ent's progress since last visit. Document specific abnormal and relevant nega8ve findings. Abnormal or

unexpected findings should be described. You should include only the informa8on which was provided in the case study, do not include addi8onal data.

Record observa2ons for the following systems if applicable to this pa2ent encounter (there are 12 possible systems for examina2on): Cons8tu8onal (e.g. vita! signs, general appearance), Eyes, ENT/ mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lympha8c/immunologic/lab tes8ng. The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every pa8ent regardless of the chief complaint.

Tes2ng Results: Results of any diagnos2c or lab tes2ng ordered during that pa2ent visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have iden8fied. These diagnoses are the conclusions you have drawn from the subjec8ve and objec8ve data.

Remember: Your subjec2ve and objec2ve data should support your diagnoses and your therapeu2c plan.

Do not write that a diagnosis is to be "ruled out" rather state the working defini8ons of each differen8al or primary diagnosis (es).

For each diagnoses provide a cited ra8onale for choosing this diagnosis. This ra8onale includes a one sentence cited defini8on of the diagnosis (es) the pathophysiology, the common signs and symptoms, the pa8ents presen8ng signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpreta8on of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this pa8ent). Each step of your plan must include an EBP cita8on.

1. Medica2ons write out the prescrip8on including dispensing informa8on and provide EBP to support ordering each medica8on. Be sure to include both prescrip8on and OTC medica8ons.

2. Addi2onal diagnos2c tests include EBP cita8ons to support ordering addi8onal tests

3. Educa2on this is part of the chart and should be brief, this is not a pa8ent educa8on sheet and needs to have a reference.

4. Referrals include cita8ons to support a referral

5. Follow up. Pa8ent follow-up should be specified with 8me or circumstances of return. You must provide a reference for your decision on when to follow up.