Review the Problem-Based Learning: Patients’ Background StoryLinks to an external site. and the Problem-Based Learning: EENT Visit with JackLinks to an external site..http://media.samuelmerritt.edu/N675/pbl/pbl_background/story.html and http://media.samuelmerritt.edu/N675/pbl/pbl_w01_eent_jack/story.html. read both of these links above as mentioned to complete the soap note.
This course mimics a problem-based learning (PBL) style in which you diagnose a patient based on the line of questions asked and symptoms displayed. The patients shown in the case studies are used throughout this course showing different symptoms.
Note: The clinic visit story may not have all the information needed or would normally get during a patient visit. Consider what questions you would ask, or physical exam you would do to the patient in this story while in your clinic. If the story does not have the answers or the necessary physical exam done, come up with your own realistic answers and physical exam that fit the narrative of the story and diagnosis.
Create a SOAP note using the SOAP Note Template for Jack’s chief complaint (CC) for this week.
Submit your SOAP note
Below is the grading rubric for this assignment:
SOAP Note 675 (1)
SOAP Note 675 (1)
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective
HPI, All histories, Medications, Allergies, ROS
5 pts
Exceeds
Complete and concise summary of pertinent subjective information.
4 pts
Met
Well organized; partial but accurate summary of pertinent information (>80%).
3 pts
Not Met
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than subjective info provided.
0 pts
Not Acceptable
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
5 pts
This criterion is linked to a Learning OutcomeObjective
Physical Exam, Diagnostics History
5 pts
Exceeds
Complete and concise summary of pertinent objective information.
4 pts
Met
Partial but accurate summary of pertinent objective information (>80%).
3 pts
Not Met
Poorly organized and/or limited summary of pertinent information (50%-80%); information other than objective info provided.
0 pts
Not Acceptable
Less than 50% of pertinent information is addressed; or is grossly incomplete and/or inaccurate.
5 pts
This criterion is linked to a Learning OutcomeDifferential Diagnosis
5 different differential diagnosis (NOT including the actual diagnosis for the patient).
At least 1 differential diagnosis should be a RED Flag diagnosis
10 pts
Exceeds
Complete list of 5 different differential diagnosis. 1 differential diagnosis is a red flag diagnosis. Diagnoses are rationally prioritized. Each diagnosis is thoroughly explained with the information provided in the case/SOAP note, accurate pertinent negatives and positives are listed. No extraneous information or issues listed
8 pts
Met
Complete list of 5 different differential diagnosis. 1 differential diagnosis is a red flag diagnosis. Diagnoses may be partially prioritized. Each diagnosis is explained with the information provided in the case/SOAP note, explanation may have small inaccuracies. No extraneous information or issues listed
6 pts
Not Met
Less than 5 different differential diagnosis are listed OR a red flag diagnosis is note listed. Some of the differential diagnosis are not appropriate. Differential Diagnoses are not rationally prioritized. Only some of the diagnoses Are explained with the information provided in the case/SOAP note, Some of the explanation may be inaccurate.
0 pts
Not Acceptable
Less than 2 differential diagnosis are provided. Explanation for each differential diagnosis is not provided OR most of the explanations are inaccurate.
10 pts
This criterion is linked to a Learning OutcomeAssessment
10 pts
Exceeds
An optimal and thorough assessment is present for each problem. Each diagnosis is a diagnosable ICD 10 diagnosis. Each diagnosis is thoroughly explained with the information provided in the case/SOAP note, accurate pertinent negatives and positives are listed.
8 pts
Met
An assessment is present for each problem listed but not optimal. Each diagnosis is a diagnosable ICD 10 diagnosis. Each diagnosis is explained with the information provided in the case/SOAP note, there may be slight inaccuracies in the explanation of pertinent negatives and positives are listed.
6 pts
Not Met
Assessment is present for 50-80% of problems. Only some (>50%) of the diagnosis are ICD 10 diagnosis. Most diagnoses are explained with the information provided in the case/SOAP note, there may be inaccuracies in the explanation of pertinent negatives and positives are listed, but > 50% is accurate.
0 pts
Not Acceptable
Less than 50% of problems include an appropriate assessment. Most of the diagnosis are ICD 10 diagnosis. Some diagnoses are explained with the information provided in the case/SOAP note, there may be inaccuracies in the explanation of pertinent negatives and positives are listed, 80%). Treatment Plan is complete and appropriate for each identified problem (>80%).
6 pts
Not Met
Appropriate therapeutic goals for a few identified problems (50%-80%). Treatment plan is partially complete and/or inappropriate for a few identified problems (50%-80%); information other than necessary “plan” information is provided.
0 pts
Not Acceptable
Less than 50% of problems have appropriate therapeutic goals. Less than 50% of problems have an appropriate and complete treatment plan.
10 pts
This criterion is linked to a Learning OutcomeCounseling, Referral/Follow Up, Patient Education
5 pts
Exceeds
Specific patient education points, monitoring parameters, follow-up plan and (where applicable) referral plan for each identified problem.
4 pts
Met
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for >80% of identified problems.
3 pts
Not Met
Patient education points, monitoring parameters, follow-up plan and referral plan (where applicable) for a few identified problems (50%-80%).
0 pts
Not Acceptable
Less than 50% of problems include appropriate counseling, monitoring, referral and/or follow-up plan.
5 pts
This criterion is linked to a Learning OutcomeRefences
2.5 pts
Exceeds
All references are appropriately cited via APA. All references are primary sources less than 10 years old *(unless landmark study/paper)
2 pts
Met
Most (>80%) references are appropriately cited via APA. All references are primary sources but may be more than 10 years old
1.5 pts
Not Met
Some (>50-80%) references are appropriately cited via APA. Most references are primary sources but may be more than 10 years old
0 pts
Not Acceptable
Only some (<50%) references are appropriately cited via APA. Only some of the references are primary sources
2.5 pts
This criterion is linked to a Learning OutcomeSBAR Report
2.5 pts
Exceeds
The SBAR report is exceptionally clear, but includes only the necessary pertinent positives and negatives of the case. Information is accurately and succinctly organized following the SBAR format. The SBAR correlates exceptionally well to the SOAP note Report is well-structured, with no major grammatical or spelling errors.
2 pts
Met
The SBAR report is clear and accurately reflects the case study. Information is organized appropriately according to the SBAR format. Includes all necessary details relevant to the case without unnecessary information. Shows good clinical reasoning and decision-making skills. Report is structured correctly, with minimal grammatical or spelling errors.
1.5 pts
Not Met
The SBAR report partially reflects the case study but lacks some important details. Some elements of the SBAR format are missing or not clearly presented. The report includes some relevant details but omits others that are crucial for understanding. Clinical reasoning and decision-making skills are not clearly demonstrated. Report structure has several grammatical or spelling errors.
0 pts
Not Acceptable
The SBAR report does not adequately reflect the case study. Fails to follow the SBAR format or the format is used incorrectly. Lacks critical details necessary for understanding the case, showing poor clinical reasoning. Report is disorganized, with multiple grammatical or spelling errors.
2.5 pts
Total Points: 50
