SOAP NOTE
Acute abdominal pain- appendicitis
The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials. Review the SOAP Note Rubric. Use a case from the previous week’s discussion or patient from your video submission or clinical practicum experience (adding content as needed to represent abnormal findings). Submit your own note. Do not submit documentation from the patient’s record.
RUBRIC
SOAP Note Rubric
[SOAP Note Rubric] – 100 PointsCriteriaExemplary
Exceeds ExpectationsAdvanced
Meets ExpectationsIntermediate
Needs ImprovementNovice
InadequateTotal Points
Subjective – 25%
Information about the patient (3 points)
Name (initials only); age, and gender
Source of information; note relationship to patient, if relevant
Reliability of information
Chief Complaint (1 point)
History of Presenting Illness (8 points)
Location
Quality
Quantity or severity
Timing (onset, duration, frequency)
Setting in which it occurs
Factors that aggravate or relieve the symptoms
Associated manifestations
Review of Focus System(s) (5 points)
Medications/Allergies (3 points)
History (5 points)
Past Medical History
Past Surgical History
Family History
Social History
Health Maintenance Practices
Patient described in appropriate detail
Concise and clear chief complaint as described by patient
HPI includes all components with appropriate detail
Comprehensive review of focus system(s) includes pertinent negatives
Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance;
Allergies to medications and reaction noted
Comprehensive health history is appropriate to reason for visit and includes pertinent negatives
25 pointsPatient described in appropriate detail
Concise and clear chief complaint as described by patient
HPI missing minor detail
Comprehensive review of focus system(s)
Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted
Comprehensive health history is appropriate to reason for visit
22 points1 detail missed in patient description
Chief complaint as described by patient, may not be concise or clear
HPI missing 1 component or significant detail
Review of focus system missing 1-2 components
Medication history missing 1-2 components
Health history not appropriate for reason for visit or missing 1-2 components
19 points>2 details missed in patient description
Chief complaint not identified, concise, or clear
HPI missing >2 components and significant detail
Review of focus system(s) missing >3 components
Medication history missing >3 components
Health history missing >3 components
17 points25Objective – 30%
Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points)
Appropriate techniques of examination used to identify pertinent findings (10 points)Appropriate areas and systems included in physical assessment
Comprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate
30 points
Missing 1 expected area of assessment
Appropriate techniques of examination used but special assessment technique missed
26 points
Missing 2 expected areas of assessment
One basic technique of examination missed
23 pointsMissing >3 expected areas of assessment
>2 techniques of examination missed
20 points30Assessment – 20%
Differential diagnoses are supported by subjective and objective findings (15 points)
Scholarly resources support differential diagnoses (5 points)Three differential diagnoses are supported by findings and include worst case scenario
Rationale for differential diagnoses provided by scholarly resources
20 pointsThree differential diagnoses include worst case scenario but one diagnosis may not be fully supported by findings
Rationale for differential diagnoses provided by scholarly resources
17 pointsDifferential diagnoses may or may not include worst case scenario and 2 differential diagnoses not supported by findings
Rationale for all differential diagnoses not provided by scholarly resources
15 points<3 differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst case scenario
Scholarly resources not provided or do not support differential diagnoses
13 points20Plan – 15%
Comprehensive plan to address likely differential diagnosis includes (9 points)
Diagnostic testing
Pharmacologic intervention
Non-pharmacologic intervention
Referrals
Patient education
Follow-up
Plan is supported by appropriate and current practice guidelines (6 points)Comprehensive plan includes all components
Appropriate and current guidelines cited
15 pointsPlan missing 1 of the identified components
Appropriate and current guidelines cited
13 pointsPlan missing 2 of the identified components
Guidelines are not current or appropriate for identified problem
12 pointsPlan missing >3 of the identified components
Guidelines for plan not cited
10 points15Documentation – 10%
Documentation follows SOAP template, is logical, and in correct format (10 points)Logical and systematic organization of data
Correct terminology, spelling, and grammar
Scholarly resources noted in correct APA format
10 pointsLogical and systematic organization of data
Terminology, spelling, grammar or format errors (1-3)
8 pointsMinor errors in organization of data
Terminology, spelling, grammar, or format errors (4-5)
7 pointsDisorganized flow of data
Terminology, spelling, grammar or format errors (>5)
6 points10Total Points100
0 comments:
Post a Comment