Assignments:
FOCUSED SOAP NOTE
GUIDE and RUBRIC
The SOAP note should
mimic clinical documentation in the practicum setting. The documentation should be accurate, clear,
well organized and utilizes medical terminology.
SUBJECTIVE (20
points)
CC –
the reason for the visit as stated in the patient’s own
words
Example: “I have been coughing
frequently for 5 days.”
HPI (History of
Present Illness) –
Describe the chief
complaint in a chronologic manner and include symptom dimensions, chronological
narrative of patient’s complains. Use PQRST or OLDCARTS mnemonic to
guide you in obtaining pertinent information. If the information is obtained
from other sources, always identify the source
First sentence should include patient’s identifying data,
including age, gender, (and race if clinically relevant), and pertinent past
medical history.
Incorporate elements
of the PMHx, FHx and SHx relevant to the patient’s chief complaint.
Include pertinent
positives and negatives based on relevant portions of the R.O.S.
HPI should present
the context for the differential diagnoses.
Elaborate briefly
about the chronic condition that maybe directly related to the chief complaint ( In the example below, Asthma is a relevant
chronic problem to discuss in a focused SOAP, since it maybe one of the
differentials in the setting of a cough)
For example:
Mr. X is a 54 year
old man with asthma, who presents with persistent cough X 5 days, worse at
night with small amount of whitish sputum, etc. (include all pertinent
negatives and pertinent positives to the chief complaint).
Asthma was diagnosed
5 years ago, triggered by exercise and cold weather, and treated with inhalers
as needed. Reports that he last used inhalers one month ago.
PMH (Pertinent past
medical history)
Medications –
Current medications (list with daily dosages).
Allergies Describe
the nature of the adverse reaction
Pertinent Family History, Social History and other
subjective data if relevant to the patient’s presenting problem and diagnosis.
ROS (Pertinent
review of systems) – a system- based list of questions that help uncover
symptoms not otherwise mentioned by the patient. In a focused SOAP note, only include
systems pertinent to the presenting problem and/or diagnosis. Follow the proper order of the different
systems.
OBJECTIVE (20
points)
Vital signs
PE – focused
physical exam finding limited to systems pertinent to the problem
Same systems
reviewed in ROS should be addressed in PE. Follow the proper order of the
different systems in physical exam.
Laboratory or
diagnostic data if applicable (date of these diagnostics; before this visit or
during this visit). Laboratory or diagnostic data prior to this visit belong in
the Objective section, following PE.
Labs/diagnostics that are part of the work-up to confirm or exclude a
diagnosis during this visit, belong under Plan
ASSESSMENT
(Problem List) with ICD-10 Codes
This section documents the
synthesis of subjective and objective evidence to arrive at a diagnosis. This
is the assessment of the patient’s status through analysis of the problem,
possible interactions of the problems, and changes or progress in the status of
the problems. List the problem list
(diagnosis/es) in order of importance.
The assessment could also contain
the possible causes of the patient’s problem, especially if the patient is
experiencing an illness.
If the patient had made a visit
before, it should also contain the progress which had been made since the last
visit as well as the overall progress towards fully treating the symptoms,
based on the perspective of the main physician.
Assessment should address the
relevant chronic medical condition
Example:
#1 acute viral
bronchitis (J20.9) – Mr. X is a 54 yr old man with asthma, who presents with an acute onset of persistent cough x 5
days, worse at night with small amount of whitish sputum, without SOB, fever
and chills, and with a normal lung exam. Symptoms are most likely consistent
with acute viral bronchitis.
#2 Asthma ( I10),
controlled. No recent use of inhalers
and no wheezing on exam (ex. Of how you address the patient’s major medical
condition in Assessment)
PLAN
This has to be evidence
based using the latest clinical guideline.
This should include pharmacologic, non-pharmacologic, education,
referrals and follow-up – when applicable. The plan should be personalized and
appropriate for the patient. The plan should address all the problems in
Assessment.
Example:
#1 acute viral
bronchitis (J20.9)
– supportive care, no antibiotic therapy
– OTC Dextromethorphan/guaifenesin 10ml Q4hrs
– Avoid decongestants due to HTN
– Follow up in 1 week if no improvement or if
condition worsens, a CXR can be done to r/o pneumonia.
#2 Asthma,
controlled (ex. Of how you include chronic conditions in your plan)
– continue inhalers as needed
DIFFERENTIAL
DIAGNOSES (See Rubric) include ICD-10 Codes and Evidence- Based Rationale (20
points)
– Identify 3 differential diagnoses related to
the chief complaint. Include the Most
LIKELY diagnosis/diagnoses in your differential. Order your differential to reflect the most
likely or more serious first. Provide a brief
rationale for each differential diagnosis (3-4 sentences) – rationale should
provide data that support your differential diagnoses – presentation, PE
finding and/or lab/diagnostic test results that make it similar to the
diagnosis and explain the difference between the differential and working diagnoses
and/or the laboratory/diagnostic tests that would make the diagnosis. . Explain what
makes it likely and what makes it less likely. Cite.
– Briefly discuss the rationale of the plan. Provide
clinical guidelines used to support the plan, cite.
SOAP NOTE
RUBRIC
Not Acceptable
Needs Improvement
Proficient
Excellent
Subjective
(20
points)
Subjective assessment is missing several critical
elements needed to adequately evaluate the client problem. Irrelevant information predominates
subjective assessment.
0 points
Subjective assessment is missing 3-4 key elements
needed to adequately evaluate the client’s problem. Includes irrelevant information.
10 points
Subjective assessment is missing 1-2 key elements
needed to adequately evaluate the client’s problem.
15 points
Subjective assessment of health status is focused
and fully explicated. CC is
succinct. HPI information is fully
developed and included. Elements of
the PMH, FH, and ROS that expand on the CC and HP information are included
and organized appropriately.
20 points
Objective
(20
points)
Objective assessment is not well developed, missing
several elements and/or the assessment is inappropriate.
0 points
Objective assessment is missing 3-4 key elements to
adequately evaluate the client’s problem.
10 points
Objective assessment is missing 1-2 key elements to
adequately evaluate the client’s problem.
15 points
Objective assessment of health status is fully
explicated. Includes appropriate and
relevant data.
20 points
Assessment
with ICD-10 codes
(20
points)
Inappropriate final diagnosis.
0 points
Final diagnoses considered is incomplete or only minimally
applicable for assessments. Missing ICD-10 codes or other problems not
identified.
10 points
Appropriate final diagnosis selected, limited problem
list identified, may be missing ICD 10 or limited subjective and objective
data to support diagnosi/es. Incomplete problem list.
15 points
Accurate problem identification and prioritization
supported logically by the subjective and objective data. Exhibits clear understanding of the
patient’s current condition(s).
Complete problem list identified (when applicable)
with an optimal assessment for each problem. ICD-10 codes are included and
accurate.
20 points
Plan
(20
points)
Plan is inappropriate, lacking essential components
related to final diagnoses.
0 points
Plan is inadequate to fully address the identified
problem. Needs to consider
alternatives for optimal outcomes or lacking use of clinical guidelines.
10 points
Plan is appropriate and meets criteria but is not
individualized for the client.
15 points
Plan is appropriate and comprehensive for diagnosis
and adequately addresses the problem identified. Plan is economically sound and utilizes the
current clinical guidelines.
20 points
Differential
Diagnoses and Evidence-Based Rationale
(20
points)
Missing differential diagnoses and evidence-based
rationale.
0 points
Limited differential diagnoses considered and/or
final diagnoses, missing evidence based rationale to support diagnoses on 2
or more diagnoses.
Evidence-based rationale is incomplete.
10 points
Limited differential diagnoses or limited evidenced
based rationale to support diagnoses on 2 diagnosis provided.
Evidence-based rationale is provided but not fully
explicated.
15 points
Identifies 3 appropriate differential diagnoses with
a brief rationale to support the consideration of these diagnosis. Appropriate citation and evidence-based
references provided.
Provides a rationale of the plan (above). Plan is supported by the latest clinical
guidelines. Appropriate citation and
evidence-based references provided.
20 points
A few reminders:
a chief complaint should be the reason for the visit in the patient’s words “I have a bad cough”. It is not part of your history with detailed info.
ROS and PE should be focused and pertinent. For example, I do not need a full cranial nerve exam for a patient with the flu. Cardiac and respiratory systems should always be assessed, regardless of presentation, plus whichever systems you find to be pertinent with your presenting symptoms and suspected case. Points will be deducted if the ROS and PE are comprehensive.
in your plan/problem list- please include all of patient’s comorbidities, whether un-controlled or controlled and any education you would provide to the patient regarding this diagnosis. Please see example with hypertension in the syllabus on page 12. If the hypertension were not controlled, what would you do? Continue to monitor? Increase medication? When you see a patient for any type of visit, you need to look at the whole picture and not just the presenting symptom. Are they overdue for labs for hyperlipidemia? CKD? etc.
Three differential diagnoses must be given for full credit in addition to your working diagnosis for a total of four diagnoses
I know this seems like a lot but I just wanted to go over common mistakes in order to give you the opportunity for full credit. Please review the grading rubric prior to submission as this is what I will be using when I grade them.
Pt is a 75 yr old male whose came into the office saying i’m confused and it hurts when i pee. Here are the pictures with his information to write the foucsed note
