This sheet is to help you understand what we are looking for, and what
our margin remarks might be about on your write ups of patients. Since at all
of the white-ups that you hand in are uniform, this represents what MUST be
included in every write-up.
1) Identifying Data (___5pts): The opening
list of the note. It contains age, sex, race, marital status, etc. The patient
complaint 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 in
the subjective and under the appropriate number.
2) Subjective Data (___30pts.): This is
the 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 and
negatives (10pts).
c) Any
PMH, family hx, social hx, allergies, medications related to the
complaint/problem (10pts). If more than one chief complaint, each should be
written u in this manner.
3)
Objective
Data(__25pt.): Vital signs need to be present. Height and
Weight should be included where appropriate.
a)
Appropriate systems are examined, listed in
the note and consistent with those identified in 2b.(10pts).
b)
Pertinent positives and negatives must be
documented for each relevant system.
c)
Any
abnormalities 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 listed
and worded appropriately including ICD10 codes.
5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along
with the pharmacological and non-pharmacological measures. If you have more
than one diagnosis, it is helpful to have this section divided into separate
numbered sections.
6) Subjective/ Objective, Assessment and Management and Consistent
(___10pts.): Does the
note support the appropriate differential diagnosis process? Is there evidence
that you know what systems and what symptoms go with which complaints? The
assessment/diagnoses should be consistent with the subjective section and then
the assessment and plan. The management should be consistent with the
assessment/ diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments:
Total Score: ____________
Instructor: __________________________________
Guidelines for Focused
SOAP 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).
Chief
Complaint (CC): a statement describing the patient’s symptoms, problems,
condition, diagnosis, physician-recommended return(s) for this patient visit.
The patient’s own words should be in quotes.
History
of present illness (HPI): a chronological description of the development of the
patient’s chief complaint from the first symptom or from the previous encounter
to 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.
Past
Medical History (PMH): Update current medications, allergies,
prior illnesses and injuries, operations and hospitalizations allergies,
age-appropriate immunization status.
Family
History (FH):
Update significant medical information about the patient’s family (parents,
siblings, and children). Include specific diseases related to problems
identified in CC, HPI or ROS.
Social
History(SH): An
age-appropriate review of significant activities that may include information
such as marital status, living arrangements, occupation, history of use of
drugs, alcohol or tobacco, extent of education and sexual history.
Review
of Systems (ROS). There are 14 systems for review. List positive
findings and pertinent negatives in systems directly related to the systems
identified 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 findings
section.
0:
OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient
physical exam should be performed to evaluate areas suggested by the history
and patient’s progress since last visit. Document specific abnormal and
relevant negative findings. Abnormal or
unexpected findings should be described. You should include only the
information which was provided in the case study, do not include additional
data.
Record
observations 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 systems
for which you have been given data.
NOTE: Cardiovascular and Respiratory
systems should be assessed on every patient regardless of the chief complaint.
Testing
Results: Results of any diagnostic or lab testing ordered during that patient
visit.
A:
ASSESSMENT: (this is your diagnosis (es) with the
appropriate ICD 10 code)
List
and number the possible diagnoses (problems) you have identified. These
diagnoses are the conclusions you have drawn from the subjective and objective
data.
Remember: Your subjective and objective data should
support your diagnoses and your therapeutic plan.
Do
not write that a diagnosis is to be “ruled out” rather state the
working definitions of each differential or primary diagnosis (es).
For
each diagnoses provide a cited rationale for choosing this diagnosis. This
rationale includes a one sentence cited definition of the diagnosis (es) the
pathophysiology, the common signs and symptoms, the patients presenting signs
and 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 explain
how those results support your chosen diagnosis.
P:
PLAN (this is your treatment plan specific to this
patient). Each step of your plan must include an EBP citation.
1.
Medications write out the prescription including dispensing
information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC
medications.
2.
Additional diagnostic tests include EBP citations to support
ordering additional tests
3.
Education this is part of the chart and should be brief, this
is not a patient education sheet and needs to have a reference.
4.
Referrals include citations to support a referral
5.
Follow up. Patient
follow-up should be specified with time or circumstances of return. You must
provide a reference for your decision on when to follow up.
