NUR 612 Assignment: Soap Notes Template Paper

SOAP Notes 2

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive SOAP note is to be written using the attached template below.

Comprehensive Women’s H & P Template.docx Download Comprehensive Women’s H & P Template.docx

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For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

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

Submission Instructions:

Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.

PLEASE FOLLOW THE RUBRIC-my last SOAP note I received a 57/100.

Please choose a women’s health STD for this SOAP note and use the attached template.

SOAP Notes Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeChief Complaint (Reason for seeking health care) – S

4 pts

Distinguished

Includes a direct quote from patient about presenting problem

3 pts

Excellent

Includes a direct quote from patient and other unrelated information

2 pts

Fair

Includes information but information is NOT a direct quote

0 pts

Poor

Information is completely missing
4 pts

This criterion is linked to a Learning OutcomeDemographics – S

2 pts

Distinguished

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

1.5 pts

Excellent

Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)

1 pts

Fair

Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)

0 pts

Poor

Information is completely missing

2 pts

This criterion is linked to a Learning OutcomeHistory of the Present Illness (HPI) – S
5 pts

Distinguished

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

3 pts

Excellent

Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

2 pts

Fair

Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

0 pts

Poor

Information is completely missing
5 pts

This criterion is linked to a Learning OutcomeAllergies – S
2 pts

Distinguished

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

1.5 pts

Excellent

If allergies are present, students lists type Drug, environemtal factor, herbal, food, latex name and includes severity of allergy OR description of allergy

1 pts

Fair

If allergies are present, students lists only the type of allergy name

0 pts

Poor

Information is completely missing

2 pts

This criterion is linked to a Learning OutcomeReview of Systems (ROS) – S

12 pts

Distinguished

Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”

6 pts

Excellent

Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies”

3 pts

Fair

Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies”

0 pts

Poor

Information is completely missing
12 pts

This criterion is linked to a Learning OutcomeVital Signs – O
2 pts

Distinguished

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.)

1.5 pts

Excellent

Includes 7 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.)

1 pts

Fair

Includes 6 or less 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.)

0 pts

Poor

Information is completely missing

2 pts

This criterion is linked to a Learning OutcomeLabs – O
3 pts

Distinguished

Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.

2 pts

Excellent

Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.

1 pts

Fair

Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.

0 pts

Poor

Information is completely missing
3 pts

This criterion is linked to a Learning OutcomeMedications – O
4 pts

Distinguished

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

2 pts

Excellent

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency)

1 pts

Fair

Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)

0 pts

Poor

Information is completely missing
4 pts

This criterion is linked to a Learning OutcomeScreenings – O

3 pts

Distinguished

Includes an assessment of at least 5 screening tests

2 pts

Excellent

Includes an assessment of at least 4 screening tests

1 pts

Fair

Includes an assessment of at least 3 screening tests

0 pts

Poor

Information is completely missing
3 pts

This criterion is linked to a Learning OutcomePast Medical History – O

3 pts

Distinguished

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

2 pts

Excellent

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

1 pts

Fair

Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current

0 pts

Poor

Information is completely missing

3 pts

This criterion is linked to a Learning OutcomePast Surgical History – O

3 pts

Distinguished

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

2 pts

Excellent

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

1 pts

Fair

Includes, for each surgical procedure but not the year of procedure or indication of the procedure

0 pts

Poor

Information is completely missing
3 pts

This criterion is linked to a Learning OutcomeFamily History – O
3 pts

Distinguished

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

2 pts

Excellent

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Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

1 pts

Fair

Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

0 pts

Poor

Information is completely missing

3 pts

This criterion is linked to a Learning OutcomeSocial History – O
3 pts

Distinguished

Includes all 11 of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

2 pts

Excellent

Includes 10 of the 11 following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

1 pts

Fair

Includes 9 or less of the following: tobacco use, drug use, alcohol use, marital status, employment status, current and previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

0 pts

Poor

Information is completely missing
3 pts

This criterion is linked to a Learning OutcomePhysical Examination – O

12 pts

Distinguished

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

6 pts

Excellent

Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint

3 pts

Fair

Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint

0 pts

Poor

Information is completely missing
12 pts

This criterion is linked to a Learning OutcomeDiagnosis – A
5 pts

Distinguished

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

3 pts

Excellent

Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority

2 pts

Fair

Includes an inaccurate diagnosis as the principal diagnosis

0 pts

Poor

Information is completely missing

5 pts

This criterion is linked to a Learning OutcomeDifferential Diagnosis – A

5 pts

Distinguished

Includes at least 3 differential diagnoses for the principal diagnosis

3 pts

Excellent

Includes 2 differential diagnoses for the principal diagnosis

2 pts

Fair

Includes 1 differential diagnosis for the principal diagnosis

0 pts

Poor

Information is completely missing
5 pts

This criterion is linked to a Learning OutcomePharmacologic treatment plan – P

5 pts

Distinguished

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

3 pts

Excellent

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the following 7: the 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.

2 pts

Fair

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the following: the 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.

0 pts

Poor

Information is completely missing

5 pts

This criterion is linked to a Learning OutcomeDiagnostic/Lab Testing – P

5 pts

Distinguished

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

3 pts

Excellent

Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”

2 pts

Fair

Includes appropriate diagnostic testing less than 50% of the time.

0 pts

Poor

Information is completely missing
5 pts

This criterion is linked to a Learning OutcomeEducation – P

5 pts

Distinguished

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.

3 pts

Excellent

Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self-management methods on how to incorporate healthy behaviors into their lives.

2 pts

Fair

Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self-management methods on how to incorporate healthy behaviors into their lives.

0 pts

Poor

Information is completely missing
5 pts

This criterion is linked to a Learning OutcomeAnticipatory Guidance – P
4 pts

Distinguished

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))

2 pts

Excellent

Includes at least 2 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))

1 pts

Fair

Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening))

0 pts

Poor

Information is completely missing

4 pts

This criterion is linked to a Learning OutcomeFollow up plan – P

4 pts

Distinguished

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

2 pts

Excellent

Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)

0 pts

Poor

Does not include follow up plan

4 pts

This criterion is linked to a Learning OutcomeReferences

3 pts

Distinguished

High level of APA precision

2 pts

Excellent

Moderate level of APA precision

1 pts

Fair

Incorrect APA style

0 pts

Poor

Information is completely missing

3 pts

This criterion is linked to a Learning OutcomeGrammar

3 pts

Distinguished

Free of grammar and spelling errors

2 pts

Excellent

Writing mechanics need more precision and attention to detail

0 pts

Poor

Writing mechanics need serious attention
3 pts

Total Points: 100

NUR 612 Assignment: Soap Notes Template Paper