wk5instruction.pdf

Week 5 Problem-Focused SOAP Note

Problem-focused SOAP Note Format

Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC): A short statement about why they are there

• History of Present Illness (HPI): Write your HPI in paragraph form. Start with the age,

gender, and why they are there (example: 23-year-old female here for…). Elaborate

using the acronym OLDCART: Onset, Location, Duration, Characteristics,

Aggravating/Alleviating Factors, Relieving Factors, Treatment

• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications,

allergies, immunizations, and preventative health maintenance

• Family Hx: any history of CA, DM, HTN, MI, CVA?

• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school,

etc.

• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental,

pap, vaccines, colonoscopy)

Objective

• Vital Signs

• Physical findings listed by body systems, not paragraph form- Highlight abnormal

findings

Assessment (the diagnosis)

• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological

explanation

• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent

positives and negatives for each

Plan

• Dx Plan (lab, x-ray)

• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration,

and refill(s) (if any)

• Pt. Education, including specific medication teaching points

• Referral/Follow-up

• Health maintenance: including when screenings eye, dental, pap, vaccines,

immunizations, etc. are next due

Reference

• Compare care given to the patient with the National Standards of Care/National

Guidelines. Cite accordingly.

Rubric Problem-focused SOAP Note

Problem-focused SOAP Note

Criteria Ratings Pts

This criterion is linked to a

Learning Outcome Subjective

12.5 to >11.5 pts

Accomplished

Symptom analysis is well organized, with C/C,

OLDCART, pertinent negatives, and pertinent

positives. All data needed to support the diagnosis

& differential are present. Is complete, concise,

relevant with no extraneous data.

12.5 pts

This criterion is linked to a

Learning Outcome Objective

12.5 to >11.5 pts

Accomplished

Complete, concise, well organized and well

written and includes pertinent positive and

pertinent negative physical findings. Organized

by body system in list format. No extraneous

data.

12.5 pts

This criterion is linked to a

Learning Outcome Assessment

12.5 to >11.5 pts

Accomplished

Diagnosis and differential dx are correct with ICD

code and supported by subjective and objective

data.

12.5 pts

This criterion is linked to a

Learning Outcome Plan

12.5 to >11.5 pts

Accomplished

Plan is organized, complete and evidence-based

according to National Standards of Care.

Addresses each diagnosis and is individualized to

the specific patient and includes medication

teaching and all 5 components: (Dx plan, Tx plan,

patient education, referral/follow-up, health

maintenance).

12.5 pts

Total Points: 50

• Can you make pediatric soap note? I can give you one example, but you can change it. However,

it needs one working diagnosis with two different differential diagnoses with rationale and

pertinent positives and negatives for each. Plus ICD 10 code and cpt code.

My example case

16 yrs old male: All labs are WNL. Complains chronic Acne on face, fatigue, insomnia. Spanish

speaking, Low income. Playing video games almost all night. Prescribed Doxycycline 100mg PO

BID for two weeks no refill, Clindamycin 1% topical lotion twice a day 60 gram no refill, and

hydrogen peroxide gel for acne as prn with 2 times refills. Told mom not to play video games at

night.

However, you can change the case to other pediatric cases such as UTI, dermatitis, pruritus etc