SOAP for C.H

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

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

Submission Instructions:

• Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling. avoid n/a
• Don’t forget to write your prescription (s)
• Rubrics:
  • Chief Complaint 4 Points-Includes a direct quote from the patient about the presenting problem.
  • Demographics 2 Points-Begins with patient initials, age, race, ethnicity, and gender (5 demographics).
  • History of the Present Illness 5 Points-Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).
  • Allergies 2 Points-Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy).
  • Review of Systems 12 Points-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”.
  • Vital Signs 2 Points-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).
  • Labs 3 Points-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.
  • Medications 4 Points-Includes a list of all of the patient-reported medications and the medical diagnosis for the medication (including name, dose, route, and frequency).
  • Screenings 3 Points-Includes an assessment of at least 5 screening tests
  • Past Medical History 3 Points-Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis, and whether the diagnosis is active or current.
  • Past Surgical History 3 Points-Includes, for each surgical procedure, the year of the procedure, and the indication for the procedure.
  • Family History 3 Points-Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease, and cancer.
  • Social History 3 Points-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.
  • Physical Examination 12 Points-Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to the chief complaint.
  • Diagnosis 5 Points-Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority).
  • Differential Diagnosis 5 Points-Includes at least 3 differential diagnoses for the principal diagnosis
  • Pharmacologic Treatment Plan 5 Points-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 agents. If the diagnosis is a chronic problem, the student includes instructions on currently prescribed medications as above.
  • Diagnostic/Lab Testing 5 Points-Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
  • Education 5 Points-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.
  • Anticipatory Guidance 4 Points-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).
  • Follow-up plan 4 Points-Includes recommendation for follow-up, including time frame (i.e., x # of days/weeks/months).
  • References 3 Points-High level of APA precision.
  • Grammar 3 Points-Free of grammar and spelling errors.

  Patient MUST HAVE

• HX: Right pneumothorax hospitalized AND anxiety
• problem: left shoulder deltoid pain zero 10 out of 10 pain
  C.H52 years Hispanic male who came to four left deltoid pain, which on presentation was a nine out of 10 that has lasted for the last four days
• rest can be made up