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Problem-Focused SOAP Note Format 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, iImmunizations, and preventative health maintenance Family Hx Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc. Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy) Objective Physical findings listed by body systems, not paragraph form Assessment (the diagnosis) Three (3) differential diagnosis (if applicable) with rationale Final diagnosis with rationale and pathophysiological explanation 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): Reference Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. Rubric NURS_663L-A_DE – SOAP Note Rubric NURS_663L-A_DE – SOAP Note Rubric Criteria Ratings Pts This criterion is linked to a Learning Outcome S (Subject) 7.5 to >6.9 pts Accomplished Symptom analysis is well organized, with C/C, OLDCART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, relevant with no extraneous data. 6.9 to >6.15 pts Satisfactory Symptom analysis well organized with C/C, OLDCART, pertinent negatives, and pertinent positives. Some extraneous data present and/or one minor data point missing. 6.15 to >5.18 pts Needs Improvement Symptom analysis is not well organized. Data is missing. There is too much extraneous data and/or 2-3 minor data points missing. 5.18 to >0 pts Unsatisfactory Symptom analysis is inadequate, is not organized. Objective or other data is mixed into the subjective data. Important data is missing. 7.5 pts This criterion is linked to a Learning Outcome O (Object) 7.5 to >6.9 pts Accomplished Complete, concise, well organized and well written and includes pertinent positive and pertinent negative physical findings. Organized by body system in list format. No extraneous data. 6.9 to >6.15 pts Satisfactory All relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format. 6.15 to >5.18 pts Needs Improvement Omitted important relevant exams and/or not in list format. 5.18 to >0 pts Unsatisfactory Omitted important relevant exams and/or subjective data are included. Lacking organization. 7.5 pts This criterion is linked to a Learning Outcome A (DDX) 7.5 to >6.9 pts Accomplished Diagnosis and differential dx are correct with ICD code and supported by subjective and objective data. 6.9 to >6.15 pts Satisfactory Diagnosis is correct with ICD codes and is supported by subjective and objective data, however the most accurate differential diagnosis not listed according to subjective and objective data. 6.15 to >5.18 pts Needs Improvement Diagnosis is correct but either does not include ICD code or is missing two or more important differential diagnoses according to the subjective and objective data provided. 5.18 to >0 pts Unsatisfactory Diagnosis is not correct, is not provided or is not reflective of the subjective and objective data provided. 7.5 pts This criterion is linked to a Learning Outcome P (Plan) 7.5 to >6.9 pts Accomplished Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance). 6.9 to >6.15 pts Satisfactory Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching but may be missing 1-2 minor points. 6.15 to >5.18 pts Needs Improvement Plan is less organized and not based on evidence according to National Standards of Care. Does not address each diagnosis or may not be individualized to the specific patient. Missing medication teaching or one of the 5 components. 5.18 to >0 pts Unsatisfactory No Plan provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching. 7.5 pts Total Points: 30 See attachment for example: Problem Focused SOAP note See attachment for patient information: Mini Soap Note v2015