Soap note 2

patient 19 year old female with urinary discomfort, frequency, and urgency.
MUST FOLLOW RUBRIC SEE ATTACHED 

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

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:

SOAP NOTE TEMPLATE Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

SOAP Note Rubric

Criteria Ratings Point
s

Demographics 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
point

Chief
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
points

History 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
points

Allergies 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
points

Review 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
points

Vital 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
points

Labs 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
points

Medications 4 to >2.0 pts
Includes a list of all
of the patient
reported
medications and
the medical
diagnosis for the
medication
(including name,

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

1 to >0.0 pts
Includes a list
of all of the
patient
reported
medications
(including 2 of
the 4: name,

0 pts
Missing
criteria
and/or
submission
.

4
points

dose, route,
frequency)

the 4: name,
dose,
medications
route,
frequency)

dose, route,
frequency)

Past 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
points

Past 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
points

Family 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
points

Social 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

1 to >0.0 pts
Includes 9 or
less of the
required
information.

0 pts
Missing
criteria
and/or
submission
.

3
points

use, and living
situation.

Health
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 5 screening
tests

2 to >1.0 pts
Includes a
partial
assessment of
immunization
status and
health
maintenance
needs, missing
some key
components.
Includes an
assessment of
at least 4
screening tests

1 to >0.0 pts
Includes
minimal
assessment of
immunization
status and
health
maintenance
needs, lacking
detail.
Includes an
assessment of
at least 3
screening
tests

0 pts
Missing
criteria
and/or
submission
.

3
points

Physical
Examination

15 to >8.0 pts
Includes a
minimum of 4
assessments for
each body system
and assesses at
least 5 body
systems directed to
chief complaint

8 to >3.0 pts
Includes a
minimum of 3
assessments for
each body
system and
assesses at
least 4 body
systems
directed to chief
complaint

3 to >0.0 pts
Includes a
minimum of 2
assessments
for each body
system and
assesses at
least 4 body
systems
directed to
chief
complaint

0 pts
Missing
criteria
and/or
submission
.

15
points

Diagnosis

5 to >3.0 pts
Includes a clear
outline of the
accurate principal
diagnosis AND lists
the remaining
diagnoses
addressed at the
visit (in descending
priority)

3 to >1.0 pts
Includes a clear
outline of the
accurate
diagnoses
addressed at the
visit but does
not list the
diagnoses in
descending
order of priority

1 to >0.0 pts
Includes 1
differential
diagnosis for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

Differential
Diagnosis

5 to >3.0 pts
Includes at least 3
differential
diagnoses for the
principal diagnosis

3 to >1.0 pts
Includes at least
2 differential
diagnoses for
the principal
diagnosis

1 to >0.0 pts
Includes at
least 1
differential
diagnoses for
the principal
diagnosis

0 pts
Missing
criteria
and/or
submission
.

5
points

ICD 10 Coding 3 to >2.0 pts
Correctly includes
all ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

2 to >1.0 pts
Correctly
includes most
ICD-10 codes
relevant to the
diagnoses
addressed at the
visit

1 to >0.0 pts
Includes some
ICD-10 codes
relevant to the
diagnoses
addressed at
the visit

0 pts
Missing
criteria
and/or
submission
.

3
points

Pharmacologi
c treatment
plan

5 to >3.0 pts
Includes a detailed
pharmacologic
treatment plan for
each of the
diagnoses listed
under
“assessment”. The
plan includes ALL
of the required
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 to >1.0 pts
Includes a
detailed
pharmacologic
treatment plan
for each of the
diagnoses listed
under
“assessment”.
The plan
includes 4 of the
required
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.

1 to >0.0 pts
Includes a
detailed
pharmacologi
c treatment
plan for each
of the
diagnoses
listed under
“assessment”.
The plan
includes less
than 4 of the
information:

0 pts
Missing
criteria
and/or
submission
.

5
points

Diagnostic /
Lab Testing

3 to >2.0 pts
Includes
appropriate
diagnostic/lab
testing 100% of the
time OR
acknowledges “no
diagnostic testing
clinically required
at this time”

2 to >1.0 pts
Includes
appropriate
diagnostic/lab
testing 50% of
the time OR
acknowledges
“no diagnostic
testing clinically
required at this
time”

1 to >0.0 pts
Includes
appropriate
diagnostic
testing less
than 50% of
the time.

0 pts
Missing
criteria
and/or
submission
.

3
points

Education 3 to >2.0 pts
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.

2 to >1.0 pts
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.

1 to >0.0 pts
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

0 pts
Missing
criteria
and/or
submission
.

3
points

healthy
behaviors into
their lives

Anticipatory
Guidance

3 to >2.0 pts
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 to >1.0 pts
Includes at least
2 primary
prevention
strategies
(related to
age/condition
(i.e.
immunizations,
pediatric and
pre-natal
milestone
anticipator
guidance)) and
at least 2
secondary
prevention
strategies
(related to
age/condition
(i.e. screening))

1 to >0.0 pts
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
Missing
criteria
and/or
submission
.

3
points

Follow Up
Plan

2 to >1.0 pts
Includes
recommendation
for follow up,
including time
frame (i.e. x # of
days/weeks/months
)

1 to >0.0 pts
Includes recommendation for
follow up, but does not include
time frame (i.e. x # of
days/weeks/months)

0 pts
Missing
criteria
and/or
submission
.

2
points

Prescription 3 to >2.0 pts
Prescription
includes all
required
components:
patient information,
date, drug name,
dose, route,
frequency, quantity
to be dispensed,
refills, and
provider’s
signature and
credentials

2 to >1.0 pts
Prescription
includes most
required
components,
but is missing 1-
2 elements such
as quantity to be
dispensed or
refills

1 to >0.0 pts
Prescription is
missing 3 or
more required
components
such as
patient
information,
date, or
provider’s
signature

0 pts
Missing
criteria
and/or
submission
.

3
points

Writing
Mechanics,
Citations, and
APA Style

3 to >2.0 pts
Effectively uses the
literature and other
resources to inform
their work.
Exceptional use of
citations and
extended
referencing. APA

2 to >1.0 pts
Moderately use
the literature
and other
resources to
inform their
work.
Moderately use
of citations and

1 to >0.0 pts
Ineffectively
uses the
literature and
other
resources to
inform their
work.
Ineffectively

0 pts
Missing
criteria
and/or
submission
.

3
points

style is correct, and
writing is free of
grammar and
spelling errors.

extended
referencing. APA
style and writing
mechanics need
more precision
and attention to
detail.

use of
citations and
extended
referencing.
APA style and
writing
mechanics
need serious
attention.

Total 100