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Guidelines:
SOAP Note
Focused SOAP Note
Completed SOAP Note Examples:
Expanded Soap Note
Focused SOAP NoteGuidelines:
Assignment: Please refer to the AGACNP SOAP note resources for expectations of this assignment.
Your expanded soap note should be on a different diagnosis each week, choosing from these categories : NEUROLOGY
NeuroFrom Syllabus: The Expanded SOAP notes: reflects a thorough understanding of a patient’s condition. Students are expected to report on: Subjective and objective assessments of health status, CC and HPI, HPI is fully developed, PMH (past medical history), FH (family history), and ROS (review of systems) that expand on the chief complaint, as well as HPI (history of present illness). Your expanded soap note should be on a different diagnosis each week, choosing from five categories ( students need to cover all five over the length of the course).
RUBERIC
Identifying data and source of the history (5)
Age, gender, race, source of information other than the patient, reliability, use of interpreter is provided.
5 points
Age, gender, race, are included but source of information other than the patient, reliability, use of interpreter is not provided.
Chief Complaint (5)
One or more symptoms/concerns for which the patient is seeking care; in patient’s own words in quotations.
5 points
History of Present Illness (10)
Uses OLDCARTS to describe symptom location, quality, severity, timing setting in which it occurs, alleviating or exacerbating factors, associated symptoms.
10 points
Pertinent Past Medical History and Past Surgical History (10)
Includes relevant illnesses, diagnosed medical conditions); includes dates for surgeries.
10 points
Allergies and Intolerance (5)
Lists allergies and intolerances Include the type of reaction.
5 points
Current Medication (10)
Current medication list Includes dose and frequency of prescription, OTC and herbal supplements.
10 points
Subjective 10
Review of Systems: Presence or absence of common symptoms congruent with patient’s chief complaint. Includes pertinent positives and negatives (patient denies… or patient endorses…).
10 points
Objective 10
Elements of objective data inclusive of physical exam (10 body systems) are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS.
10 points
Assessment: Differential Diagnosis based on CC (15)
Elements in this section are adeptly documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data : includes top three differentials with rationale.
15 points
Plan (for the primary diagnosis) (15)
Elements of the plan include Diagnostics, therapeutic, Education, consultations and follow up are adeptly documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented.
15 points
ICD 10 Code E & M CPT Codes (5)
ICD-10 Code, and CPT codes provided are congruent with the clinical information provided.
5 points