s2: | Nursing

Clinical Requirement:

SOAPNoteTemplate-1-16.docx SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics Chief Complaint (Reason for seeking health care) History of Present Illness (HPI) Allergies Review of Systems (ROS) General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Vital Signs Labs Medications Past Medical History Past Surgical History Family History Social History Health Maintenance/ Screenings Physical Examination General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Diagnosis Differential Diagnosis ICD 10 Coding Pharmacologic treatment plan Diagnostic/Lab Testing Education Anticipatory Guidance Follow up plan Prescription See Below (scroll down) References Grammar EA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________ Signature (with appropriate credentials):_____________________________________ References (must use current evidence-based guidelines used to guide the care [Mandatory]) SOAPNoteRubric-11.pdf SOAP Note Rubric Criteria Ratings Point s Demographics 1 to >0.8 pts Begins with patient initials, age, race, ethnicity and gender (5 demographics) 0.8 to >0.25 pts Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender) 0.25 to >0.0 pts Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) 0 pts Missing criteria and/or submission . 1 point Chief Complaint (Reason for seeking health care) 4 to >3.0 pts Includes a direct quote from patient about presenting problem 3 to >2.0 pts Includes a direct quote from patient and other unrelated information 2 to >0.0 pts Includes information but information is NOT a direct quote 0 pts Missing criteria and/or submission . 4 points History of the Present Illness (HPI) 5 to >3.0 pts Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 3 to >2.0 pts Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 2 to >0.0 pts Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 0 pts Missing criteria and/or submission . 5 points Allergies 2 to >1.5 pts Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy) 1.5 to >1.0 pts If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy 1 to >0.0 pts If allergies are present, students lists only the type of allergy name 0 pts Missing criteria and/or submission . 2 points Review of Systems (ROS) 15 to >8.0 pts Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies” 8 to >3.0 pts Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies” 3 to >0.0 pts Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies” 0 pts Missing criteria and/or submission . 15 points Vital Signs 2 to >1.5 pts Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1.5 to >1.0 pts Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 1 to >0.0 pts Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.) 0 pts Missing criteria and/or submission . 2 points Labs 2 to >1.5 pts Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed. 1.5 to >1.0 pts Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values. 1 to >0.0 pts Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values. 0 pts Missing criteria and/or submission . 2 points Medications 4 to >2.0 pts Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, 2 to >1.0 pts Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of 1 to >0.0 pts Includes a list of all of the patient reported medications (including 2 of the 4: name, 0 pts Missing criteria and/or submission . 4 points dose, route, frequency) the 4: name, dose, medications route, frequency) dose, route, frequency) Past Medical History 3 to >2.0 pts Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current 2 to >1.0 pts Includes (Major/Chronic, Trauma, Hospitalizations) , for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current 1 to >0.0 pts Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current 0 pts Missing criteria and/or submission . 3 points Past Surgical History 3 to >2.0 pts Includes, for each surgical procedure, the year of procedure and the indication for the procedure 2 to >1.0 pts Includes, for each surgical procedure, the year of procedure OR indication of the procedure 1 to >0.0 pts Includes, for each surgical procedure but not the year of procedure or indication of the procedure 0 pts Missing criteria and/or submission . 3 points Family History 3 to >2.0 pts Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 2 to >1.0 pts Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 1 to >0.0 pts Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 0 pts Missing criteria and/or submission . 3 points Social History 3 to >2.0 pts Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation. 2 to >1.0 pts Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive 1 to >0.0 pts Includes 9 or less of the required information. 0 pts Missing criteria and/or submission . 3 points use, and living situation. Health Maintenance / Screenings 3 to >2.0 pts Includes a detailed assessment of immunization status and other health maintenance needs such as age- appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests 2 to >1.0 pts Includes a partial assessment of immunization status and health maintenance needs, missing some key components. Includes an assessment of at least 4 screening tests 1 to >0.0 pts Includes minimal assessment of immunization status and health maintenance needs, lacking detail. Includes an assessment of at least 3 screening tests 0 pts Missing criteria and/or submission . 3 points Physical Examination 15 to >8.0 pts Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint 8 to >3.0 pts Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint 3 to >0.0 pts Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint 0 pts Missing criteria and/or submission . 15 points Diagnosis 5 to >3.0 pts Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority) 3 to >1.0 pts Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority 1 to >0.0 pts Includes 1 differential diagnosis for the principal diagnosis 0 pts Missing criteria and/or submission . 5 points Differential Diagnosis 5 to >3.0 pts Includes at least 3 differential diagnoses for the principal diagnosis 3 to >1.0 pts Includes at least 2 differential diagnoses for the principal diagnosis 1 to >0.0 pts Includes at least 1 differential diagnoses for the principal diagnosis 0 pts Missing criteria and/or submission . 5 points ICD 10 Coding 3 to >2.0 pts Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit 2 to >1.0 pts Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit 1 to >0.0 pts Includes some ICD-10 codes relevant to the diagnoses addressed at the visit 0 pts Missing criteria and/or submission . 3 points Pharmacologi c treatment plan 5 to >3.0 pts Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. 3 to >1.0 pts Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the required following 7: the drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above. 1 to >0.0 pts Includes a detailed pharmacologi c treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the information: 0 pts Missing criteria and/or submission . 5 points Diagnostic / Lab Testing 3 to >2.0 pts Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time” 2 to >1.0 pts Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time” 1 to >0.0 pts Includes appropriate diagnostic testing less than 50% of the time. 0 pts Missing criteria and/or submission . 3 points Education 3 to >2.0 pts Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives. 2 to >1.0 pts Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self- management methods on how to incorporate healthy behaviors into their lives. 1 to >0.0 pts Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self- management methods on how to incorporate 0 pts Missing criteria and/or submission . 3 points healthy behaviors into their lives Anticipatory Guidance 3 to >2.0 pts Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre- natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) 2 to >1.0 pts Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipator guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening)) 1 to >0.0 pts Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations , pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening)) 0 pts Missing criteria and/or submission . 3 points Follow Up Plan 2 to >1.0 pts Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months ) 1 to >0.0 pts Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months) 0 pts Missing criteria and/or submission . 2 points Prescription 3 to >2.0 pts Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials 2 to >1.0 pts Prescription includes most required components, but is missing 1- 2 elements such as quantity to be dispensed or refills 1 to >0.0 pts Prescription is missing 3 or more required components such as patient information, date, or provider’s signature 0 pts Missing criteria and/or submission . 3 points Writing Mechanics, Citations, and APA Style 3 to >2.0 pts Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA 2 to >1.0 pts Moderately use the literature and other resources to inform their work. Moderately use of citations and 1 to >0.0 pts Ineffectively uses the literature and other resources to inform their work. Ineffectively 0 pts Missing criteria and/or submission . 3 points style is correct, and writing is free of grammar and spelling errors. extended referencing. APA style and writing mechanics need more precision and attention to detail. use of citations and extended referencing. APA style and writing mechanics need serious attention. Total 100