Maria

Week 5: Mini-SOAP Note 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, immunizations, and preventative health maintenance as applicable

• Family Hx: As applicable

• Social Hx: Including nutrition, exercise, substance use, sexual history, occupation,

school, etc.

• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental,

pap, vaccines, colonoscopy)

Objective

• Vital signs

• Physical findings listed by body systems, not paragraph form

Assessment (Diagnosis/ICD10 Code)

• Include all diagnoses that apply for this visit

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):

NURS_663L-A_DE - Mini SOAP Note Rubric

NURS_663L-A_DE - Mini SOAP Note Rubric

Criteria Ratings Pts

This criterion is linked to a Learning Outcome Professional Communication and Engagement

5 to >4.13 pts Satisfactory Addresses all instructor/ preceptor comments and makes necessary changes as needed.

5 pts

This criterion is linked to a Learning Outcome Professional Documentation 20 to >16.39 pts

Satisfactory All data fields in Medatrax are completed accurately. Mini SOAP note follows the required format and all relevant information is completed thoroughly and accurately.

20 pts

Total Points: 25