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:

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

SOAP Note Rubric

SOAP Note Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeDemographics

1 to >0.8 pts

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

0.8 to >0.25 pts

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

0.25 to >0.0 pts

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

0 pts

Missing criteria and/or submission.

1 pts

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

4 to >3.0 pts

Includes a direct quote from patient about presenting problem

3 to >2.0 pts

Includes a direct quote from patient and other unrelated information

2 to >0.0 pts

Includes information but information is NOT a direct quote

0 pts

Missing criteria and/or submission.

4 pts

This criterion is linked to a Learning OutcomeHistory of the Present Illness (HPI)

5 to >3.0 pts

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 to >2.0 pts

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 to >0.0 pts

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

Missing criteria and/or submission.

5 pts

This criterion is linked to a Learning OutcomeAllergies

2 to >1.5 pts

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)

1.5 to >1.0 pts

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

1 to >0.0 pts

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

0 pts

Missing criteria and/or submission.

2 pts

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

15 to >8.0 pts

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”

8 to >3.0 pts

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 to >0.0 pts

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

Missing criteria and/or submission.

15 pts

This criterion is linked to a Learning OutcomeVital Signs

2 to >1.5 pts

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 to >1.0 pts

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 to >0.0 pts

Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)

0 pts

Missing criteria and/or submission.

2 pts

This criterion is linked to a Learning OutcomeLabs

2 to >1.5 pts

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.

1.5 to >1.0 pts

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

1 to >0.0 pts

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

Missing criteria and/or submission.

2 pts

This criterion is linked to a Learning OutcomeMedications

4 to >2.0 pts

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

2 to >1.0 pts

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 to >0.0 pts

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

0 pts

Missing criteria and/or submission.

4 pts

This criterion is linked to a Learning OutcomePast Medical History

3 to >2.0 pts

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

2 to >1.0 pts

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

1 to >0.0 pts

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

0 pts

Missing criteria and/or submission.

3 pts

This criterion is linked to a Learning OutcomePast Surgical History

3 to >2.0 pts

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

2 to >1.0 pts

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

1 to >0.0 pts

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

0 pts

Missing criteria and/or submission.

3 pts

This criterion is linked to a Learning OutcomeFamily History

3 to >2.0 pts

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

2 to >1.0 pts

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

1 to >0.0 pts

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

0 pts

Missing criteria and/or submission.

3 pts

This criterion is linked to a Learning OutcomeSocial History

3 to >2.0 pts

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

2 to >1.0 pts

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

1 to >0.0 pts

Includes 9 or less of the required information.

0 pts

Missing criteria and/or submission.

3 pts

This criterion is linked to a Learning OutcomeHealth Maintenance / Screenings

3 to >2.0 pts

Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least

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