This sheet is to help you understand what we are looking for, and whatour margin remarks might be about on your write ups of patients. Since at allof the white-ups that you hand in are uniform, this represents what MUST beincluded in every write-up.
1) Identifying Data (___5pts): The openinglist of the note. It contains age, sex, race, marital status, etc. The patientcomplaint should be given in quotes. If the patient has more than one complaint,each complaint should be listed separately (1, 2, etc.) and each addressed inthe subjective and under the appropriate number.
2) Subjective Data (___30pts.): This isthe historical part of the note. It contains the following:
a)Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting,factors that make it better or worse, and associate manifestations.(10pts).
b)Review of systems of associated systems, reporting all pertinent positives andnegatives (10pts).
c) AnyPMH, family hx, social hx, allergies, medications related to thecomplaint/problem (10pts). If more than one chief complaint, each should bewritten u in this manner.
3) ObjectiveData(__25pt.): Vital signs need to be present. Height andWeight should be included where appropriate.
a) Appropriate systems are examined, listed inthe note and consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must bedocumented for each relevant system.
c) Anyabnormalities must be fully described. Measure and record sizes of things(likes moles, scars). Avoid using ok, clear, within normal limits,positive/ negative, and normal/abnormal to describe things. (5pts).
4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listedand worded appropriately including ICD10 codes.
5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling alongwith the pharmacological and non-pharmacological measures. If you have morethan one diagnosis, it is helpful to have this section divided into separatenumbered sections.
6) Subjective/ Objective, Assessment and Management and Consistent(___10pts.): Does thenote support the appropriate differential diagnosis process? Is there evidencethat you know what systems and what symptoms go with which complaints? Theassessment/diagnoses should be consistent with the subjective section and thenthe assessment and plan. The management should be consistent with theassessment/ diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments:
Total Score: ____________ Instructor: __________________________________
Guidelines for FocusedSOAP Notes
Label each section of the SOAP note (each body part and system).
Do not use unnecessary words or complete sentences.
Use Standard Abbreviations
S:SUBJECTIVE DATA (information the patient/caregiver tells you).
ChiefComplaint (CC): a statement describing the patients symptoms, problems,condition, diagnosis, physician-recommended return(s) for this patient visit.The patients own words should be in quotes.
Historyof present illness (HPI): a chronological description of the development of thepatient’s chief complaint from the first symptom or from the previous encounterto the present. Include the eight variables (Onset, Location, Duration,Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS),or an update on health status since the last patient encounter.
PastMedical History (PMH): Update current medications, allergies,prior illnesses and injuries, operations and hospitalizations allergies,age-appropriate immunization status.
FamilyHistory (FH):Update significant medical information about the patient’s family (parents,siblings, and children). Include specific diseases related to problemsidentified in CC, HPI or ROS.
SocialHistory(SH): Anage-appropriate review of significant activities that may include informationsuch as marital status, living arrangements, occupation, history of use ofdrugs, alcohol or tobacco, extent of education and sexual history.
Reviewof Systems (ROS). There are 14 systems for review. List positivefindings and pertinent negatives in systems directly related to the systemsidentified in the CC and symptoms which have occurred since last visit; (1)constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose,mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal,(7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast),(10) neurological, (11) psychiatric, (12) endocrine, (13)hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findingssection.
0:OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficientphysical exam should be performed to evaluate areas suggested by the historyand patient’s progress since last visit. Document specific abnormal andrelevant negative findings. Abnormal orunexpected findings should be described. You should include only theinformation which was provided in the case study, do not include additionaldata.
Recordobservations for the following systems if applicable to this patient encounter(there are 12 possible systems for examination):Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth,Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological,Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systemsfor which you have been given data.
NOTE: Cardiovascular and Respiratorysystems should be assessed on every patient regardless of the chief complaint.
TestingResults: Results of any diagnostic or lab testing ordered during that patientvisit.
A:ASSESSMENT: (this is your diagnosis (es) with theappropriate ICD 10 code)
Listand number the possible diagnoses (problems) you have identified. Thesediagnoses are the conclusions you have drawn from the subjective and objectivedata.
Remember: Your subjective and objective data shouldsupport your diagnoses and your therapeutic plan.
Donot write that a diagnosis is to be “ruled out” rather state theworking definitions of each differential or primary diagnosis (es).
Foreach diagnoses provide a cited rationale for choosing this diagnosis. Thisrationale includes a one sentence cited definition of the diagnosis (es) thepathophysiology, the common signs and symptoms, the patients presenting signsand symptoms and the focused PE findings and tests results that support the dx.Include the interpretation of all lab data given in the case study and explainhow those results support your chosen diagnosis.
P:PLAN (this is your treatment plan specific to thispatient). Each step of your plan must include an EBP citation.
1.Medications write out the prescription including dispensinginformation and provide EBP to support ordering each medication. Be sure to include both prescription and OTCmedications.
2.Additional diagnostic tests include EBP citations to supportordering additional tests
3.Education this is part of the chart and should be brief, thisis not a patient education sheet and needs to have a reference.
4.Referrals include citations to support a referral
5.Follow up. Patientfollow-up should be specified with time or circumstances of return. You mustprovide a reference for your decision on when to follow up.