DUE 7/4/2022......SOAP FOCUS NOTE....NO PLAGARISM

Element

Exceeds Expectations ≥ 90

Meets Expectations 83-89

Partially Meets Expectations 80-82

Does not meet Expectations ≤ 79

SUBJECTIVE

CC & History of Present Illness

(HPI)*

Tell the “story” of the complaint

30%

Appropriate OPQRST, the “story” of the HPI is clear, succinct and complete

Appropriate OPQRST discussed, extraneous elements included or not succinct

Missing 1-2 pertinent elements

Missing more than 2 pertinent elements

Past Medical & surgical History (PMH, PSH) relevant to the HPI

Include pertinent history (with positives and negatives)

Allergies

LMP

Medications

10%

Complete problem list of main problems with relevant PMH/PSH to the HPI explored fully

Include pertinent positives & negatives

1 element in PMH relevant to HPI missing or not explored fully

2 elements in PMH relevant to the HPI missing

Multiple elements in PMH relevant to the HPI missing

Social History

· If relevant, include:

· Sexual Hx

· Substance use (etoh, drugs, smoking)

10%

Social history relevant to the HPI covered completely

Social history missing one pertinent element

Social history missing 2 or more pertinent elements

Not addressed

Family History

5%

Family history relevant to the HPI included

Family history missing one to two pertinent elements

Family history missing more than two pertinent elements

Not addressed

Review of Systems

10%

All appropriate systems covered completely, no extraneous

All appropriate systems covered with some extraneous elements

Missing 1 appropriate system

Missing more than 1 appropriate system

OBJECTIVE

Physical Examination

(can include diagnostic tests or in clinic tests such as pregnancy test- if applicable)

15%

Appropriate based on complaint

Appropriate based on complaint with 1-2 missing systems

Appropriate based on complaint with > 3-4 missing systems

Missing > 4 elements

ASSESSMENT

Differential Diagnosis (DDx) and Main Dx for each problem

Minimum of 3 differentials diagnosis:

Patho of the problem; pertinent positives and pertinent negatives: supported by S + O data and rationale as to why that was or was not chosen for the final Dx

10%

DDX and Main Dx appropriate based on findings with complete reasoning, patho and pertinent positives and negatives included; appropriate ICD-10 and CPT coding for main Dx

Main Dx Appropriate based on findings though missing 1 key DDx

Rationale for DDX and main Dx could be better described

Appropriate but possible better one available based on findings or missing some key elements

Inappropriate based on findings

PLAN

Treatment Plan for each final diagnosis with diagnostics, referrals, pt education, follow-up parameters (each as needed)

Include HCM recommendations for this patient (see USPSTF for age-appropriate recommendations)

Cite reference for diagnosis and plan for each problem.

10%

Specific, appropriate and EBP with clear explanations for each Dx-with citations from appropriate sources

Appropriate and EBP,

Missing a few elements or explanations not clear for all Dx

Missing 1 citation

Appropriate but not first line, or missing multiple minor components

Missing > 1 citation

Inappropriate or missing multiple elements

Missing citations