SOAPnotetemplateweek3.docx

Submit a Problem-Focused SOAP note here for grading.  You must use an actual patient from your clinical practicum.  Review the rubric for more information on how your assignment will be graded. Please use a psychiatric patient (example of diagnosis GAD, MDD, PTSD

SOAP Note Template

(Use this template for this assignment)

Demographic Data

· Patient age and gender identity

· MUST BE HIPAA compliant.

Subjective

Chief Complaint (CC)

· Place the complaint in Quotes

· Brief description -only a few words and in the patient’s words…“My chest hurts”, “I cannot breath”, “I passed out”, etc.

History of Present Illness (HPI) – the reason for the appointment today

· Use the OLD CARTS acronym to document the eight elements of a chief concern (CC): Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity)

· Briefly describe the general state of health prior to the problem.

· Are Activities of Daily Living (ADL) impacted by the current problem?

Past Medical History:

· List current and past medical diagnoses

Past Surgical History:

· List all past surgeries

FAMILY HISTORY:

· Include medical/psychiatric problems to include 3 generations (parents, grandparents, siblings, or direct relatives.

Current Medications:

· Include current prescription(s), over-the-counter medications, herbal/alternative medications as well as vitamin/supplement use.

ALLERGIES: Include medications, foods, and chemicals such as latex.

Immunizations History: List current immunization status and address deficiency

SOCIAL HISTORY:

· Include nutrition, exercise, substance use (details of use: caffeine, EtOH, illicit drug use), sexual history/preference, financial problems, legal issues, kids, and history of abuse, including sexual, emotional, or physical.

· Employment/Education: occupation (type), exposure to harmful agents, highest school achievement

REVIEW OF SYSTEMS:

· A ROS is a question-seeking inventory by body systems to identify signs and/or symptoms that the patient may be experiencing or has experienced.

· Must include any physical complaint(s) by the body system that is relevant to treatment and management of the current concern(s). List only the pertinent body systems specific to the CC.

· Remember to include pertinent positive and negative findings when detailing the ROS related to a chief concern (CC).

· Do not repeat the information provided in HPI

Use the format below when detailing the ROS

ROS:

General:

Eyes:

Ears, nose, mouth & throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Skin & Breasts:

Musculoskeletal:

Allergic:

Immunologic:

Endocrine:

Hematopoietic/Lymphatic:

Genitourinary:

Neurological:

Psychiatric/Mental Status:

Objective

PHYSICAL EXAMINATION: Document by Body System including vital signs and pertinent diagnostics.

General:

Eyes:

Ears, nose, mouth & throat:

Cardiovascular:

Respiratory:

Gastrointestinal:

Skin & Breasts:

Musculoskeletal:

Allergic:

Immunologic:

Endocrine:

Hematopoietic/Lymphatic:

Genitourinary:

Neurological:

Psychiatric/Mental Status:

Assessment (Diagnosis)

Differential Diagnosis (DDx)

· Include two (2) differential diagnoses (including ICD 10 code) you considered but did not select as the final diagnosis.

· Why were these 2 diagnoses not selected? Support with pertinent positive and negative findings for each differential and support with 2 evidence-based guidelines.

Working or Final Diagnosis:

· Final or working diagnosis (including ICD-10 code)

· Provide a rational explanation supported with evidenced-based guidelines (required). List the pertinent positive and negative symptoms/signs that support your final diagnosis.

Plan

Treatment (Tx) Plan: pharmacologic and/or nonpharmacologic

· Pharmacologic -include full prescribing information for each medication(s) ordered

· Refill Provided: Include full prescribing information for each medication(s) refilled and the correlating diagnosis related to the refill.

Patient Education:

· include specific education related to each medication prescribed.

· Was risk versus benefit of current treatment plan addressed for medication(s) and interventions? Was the patient included in the medical decision making and in agreement with the final plan

· NPs should not be prescribing non-FDA approved medications or medications related to off-label use. If a physician prescribed a non-FDA-approved medication for working diagnosis or recommended off-label use was education provided and was the risk to benefit of the medication(s) addressed in the patient’s education?

Prognosis Good, Fair, or Poor?

· Indicate the patient’s prognosis: Good, Fair, Poor

· Provide support for your selected prognosis.

Referral/Follow-up

· Did you recommend follow-up with PCP, or consultation with other healthcare professionals?

· When is the subsequent follow-up?

· Include rationale for the follow-up recommendation or referral.

Disposition:

· Indicate the disposition of the patient.

· Was the patient sent home, Emergency room via EMS, etc.

Reference(s)

· Include APA formatted references.

· Minimum 2 references are required from evidence-based resources.

Students will be graded using the following rubric.

Some Rubric

Some Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning Outcome S (Subjective)	2.5 pts Accomplished Symptom analysis is well organized in a SOAP format, with C/C, Past Psychiatric Hx, Social Hx, and other pertinent past and current diagnostic details. SOAP Note is complete, concise, relevant with no extraneous data. 1.5 pts Satisfactory Symptom analysis is well organized in a SOAP format, with C/C, Past Psychiatric Hx, Social Hx, and other pertinent past and current diagnostic details. Some extraneous data present with 1 minor data point missing. 1 pts Needs Improvement Symptom analysis is not well organized or presented in a varied format. Required data is missing. There is too much extraneous data present or 2-3 minor data points are missing. 0 pts Unsatisfactory Symptom analysis is inadequate and is not organized. Objective or other data is mixed into the subjective data. Important data is missing.	2.5 pts
This criterion is linked to a Learning Outcome O (Objective)	2.5 pts Accomplished Mental Status Exam is complete, concise, well-organized, and well-written. Includes pertinent psychiatric information. Organized by MSE list format. No extraneous information is included. 1.5 pts Satisfactory Mental Status Exam is partially incomplete, organized, and satisfactorily written. Includes pertinent psychiatric information with additional extraneous information included. Somewhat organized in MSE list format. 1 pts Needs Improvement Mental Status Exam is incomplete, loosely organized with improvements required. Relevant psychiatric information is omitted. 0 pts Unsatisfactory Mental Status Exam is absent, disorganized in presentation, adheres to no specific format, or grossly omits relevant or pertinent psychiatric information.	2.5 pts
This criterion is linked to a Learning Outcome A (Assessment)	2.5 pts Accomplished Diagnosis and Differential Dx are correct with DSM-5 code(s) and supported by subjective and objective data. Includes: 1 working Dx and 2 Differential Dx. 1.5 pts Satisfactory Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data. Missing at least one (1) pertinent differential diagnosis not listed according to subjective and objective data. Working diagnosis is correct. 1 pts Needs Improvement Diagnosis and Differential Dx are correct with DSM-5 code(s) and mostly supported by subjective and objective data. Missing up to two (2) pertinent differential diagnoses based on subjective and objective data presented. Or differential diagnoses are adequate with an incorrect working diagnosis. 0 pts Unsatisfactory All diagnoses (working diagnosis and differential diagnoses) are incorrect or is missing based on the subjective and objective data presented.	2.5 pts
This criterion is linked to a Learning Outcome P (Plan)	2.5 pts Accomplished Plan is well-organized, complete, evidence-based, and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient. *Plan requirements: prescribed medications, if any; explanation of off-label medication use, if prescribed; risks and benefits of medications identified; therapy recommendations; patient education; referral/follow-up; and health maintenance. 1.5 pts Satisfactory Plan is organized, complete, evidence-based and patient-centric. Fully addresses each diagnosis and is individualized to the specific patient. Plan is missing 1-2 of the required items. 1 pts Needs Improvement Plan is less organized, is not based on evidence. Fails to address each diagnosis sufficiently or is not individualized or patient-centric Plan is missing more than 2 of the required items. 0 pts Unsatisfactory Plan is disorganized, absent, or is missing all the required items.	2.5 pts