SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive SOAP note is to be written usiWith your instructor’s permission, you may write an episodic SOAP note in place of the comprehensive. 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 upSubmission

Distinguised Excellent Fair Poor

Includes a direct quote from patient about
presenting problem

Includes a direct quote from patient and other
unrelated information

Includes information but information is NOT a
direct quote

Information is completely missing

4 Points 3 Points 2 Points 0 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)

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

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

2 Points 1.5 Points 1 Points 0 Points

Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –

Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,

Timing and Severity)

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)

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)

Information is completely missing

5 Points 3 Points 2 Points 0 Points

Includes NKA (including = Drug,
Environemental, Food, Herbal, and/or Latex
or if allergies are present (reports for each

severity of allergy AND description of
allergy)

If allergies are present, students lists type Drug,
environemtal factor, herbal, food, latex name and

includes severity of allergy OR description of
allergy

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

Information is completely missing

2 Points 1.5 Points 1 Points 0 Points

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”

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”

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”

Information is completely missing

12 Points 6 Points 3 Points 0 Points

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.)

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.)

Includes 6 or less 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.)

Information is completely missing

2 Points 1.5 Points 1 Points 0 Points

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.

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

abnormal values.

Includes a list of the labs reviewed at the visit but
does not include the values of lab results or

highlight abnormal values. Information is completely missing

3 Points 2 Points 1 Points 0 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for

the medication (including name, dose, route,
frequency)

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)

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

route, frequency) Information is completely missing

Subjective

Objective

Medications

Labs

Review of Systems (ROS)

History of the Present Illness (HPI)

Demographics

Chief Complaint (Reason for seeking
health care)

Allergies

Vital Signs

4 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 5

screening tests
Includes an assessment of at least 4 screening

tests
Includes an assessment of at least 3 screening

tests
Information is completely missing

3 Points 2 Points 1 Points 0 Points

Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis

is active or current

Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,

either year of diagnosis OR whether the diagnosis
is active or current

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

diagnosis is active or current Information is completely missing

3 Points 2 Points 1 Points 0 Points

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

procedure

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

Includes, for each surgical procedure but not the
year of procedure or indication of the procedure Information is completely missing

3 Points 2 Points 1 Points 0 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic

disorders, diabetes, heart disease and
cancer.

Includes an assessment of at least 3 family
members regarding, at a minimum, genetic

disorders, diabetes, heart disease and cancer.

Includes an assessment of at least 2 family
members regarding, at a minimum, genetic

disorders, diabetes, heart disease and cancer.
Information is completely missing

3 Points 2 Points 1 Points 0 Points

Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous

occupation, sexual orientation, sexually
active, contraceptive use, and living

situation.

Includes 10 of the 11 following: tobacco use,
drug use, alcohol use, marital status, employment

status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,

and living situation.

Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment

status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,

and living situation.

Information is completely missing

3 Points 2 Points 1 Points 0 Points

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

Includes a minimum of 3 assessments for each
body system and assesses at least 4 body systems

directed to chief complaint

Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems

directed to chief complaint
Information is completely missing

12 Points 6 Points 3 Points 0 Points

Includes a clear outline of the accurate
principal diagnosis AND lists the remaining

diagnoses addressed at the visit (in
descending priority)

Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority

Includes an inaccurate diagnosis as the principal
diagnosis

Information is completely missing

5 Points 3 Points 2 Points 0 Points

Includes at least 3 differential diagnoses for
the principal diagnosis

Includes 2 differential diagnoses for the principal
diagnosis

Includes 1 differential diagnosis for the principal
diagnosis

Information is completely missing

5 Points 3 Points 2 Points 0 Points

Diagnosis

Assessment

Plan

Family History

Screenings

Past Medical History

Differential Diagnosis

Social History

Past Surgical History

Physical Examination

Includes a detailed pharmacologic treatment
plan for each of the diagnoses listed under
“assessment”. The plan includes ALL of

the 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.

Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under

“assessment”. The plan includes 4 of the
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.

Includes a detailed pharmacologic treatment plan
for each of the diagnoses listed under

“assessment”. The plan includes less than 4 of
the following: 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.

Information is completely missing

5 Points 3 Points 2 Points 0 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no

diagnostic testing clinically required at this
time”

Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic

testing clinically required at this time”

Includes appropriate diagnostic testing less than
50% of the time.

Information is completely missing

5 Points 3 Points 2 Points 0 Points

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.

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.

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 healthy behaviors into their lives.

Information is completely missing

5 Points 3 Points 2 Points 0 Points

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))

Includes at least 2 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))

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))

Information is completely missing

4 Points 2 Points 1 Points 0 Points
Includes recommendation for follow up,

including time frame (i.e. x # of
days/weeks/months)

Includes recommendation for follow up, but does
not include time frame (i.e. x # of

days/weeks/months)
Does not include follow up plan

4 Points 2 Points 0 Points 0 Points

High level of APA precision Moderate level of APA precision Incorrect APA style Information is completely missing

3 Points 2 Points 1 Points 0 Points

Free of grammar and spelling errors
Writing mechanics need more precision and

attention to detail
Writing mechanics need serious attention

3 Points 2 Points 0 Points 0 Points

Pharmacologic treatment plan

Follow up plan

Writing

Grammar

References

Diagnostic/Lab Testing

Anticipatory Guidance

Education

Sheet1

SOAP Note Template

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health: Excellent Good Fair Poor

Past Medical History

· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Family History: ____________________________________________________________

Social history:

Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone: _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1.

2.

3.

Principal Diagnoses

1.

2.

Plan

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 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: ____________________________________________________________

Copyright © MVJ 2018




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