SOAP 1 OB: A SOAP note is a method of... | Nursing

Clinical Requirement:

A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers. Instructions: SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below. For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym: S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient's condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up SOAP Note RubricSOAP Note RubricCriteriaRatingsPts 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 pts Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) 0 pts Missing criteria and/or submission. / 1 pts Chief Complaint (Reason for seeking health care) 4 to >3 pts Includes a direct quote from patient about presenting problem 3 to >2 pts Includes a direct quote from patient and other unrelated information 2 to >0 pts Includes information but information is NOT a direct quote 0 pts Missing criteria and/or submission. / 4 pts History of the Present Illness (HPI) 5 to >3 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 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 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 pts 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 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 pts If allergies are present, students lists only the type of allergy name 0 pts Missing criteria and/or submission. / 2 pts Review of Systems (ROS) 15 to >8 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 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 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 pts 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 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 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 pts 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 pts Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values. 1 to >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 pts Medications 4 to >2 pts Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency) 2 to >1 pts Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency) 1 to >0 pts Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency) 0 pts Missing criteria and/or submission. / 4 pts Past Medical History 3 to >2 pts Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current 2 to >1 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 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 pts Past Surgical History 3 to >2 pts Includes, for each surgical procedure, the year of procedure and the indication for the procedure 2 to >1 pts Includes, for each surgical procedure, the year of procedure OR indication of the procedure 1 to >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 pts Family History 3 to >2 pts Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 2 to >1 pts Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer. 1 to >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 pts Social History 3 to >2 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 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 use, and living situation. 1 to >0 pts Includes 9 or less of the required information. 0 pts Missing criteria and/or submission. / 3 pts Health Maintenance / Screenings 3 to >2 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 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 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 pts Physical Examination 15 to >8 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 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 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 pts Diagnosis 5 to >3 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 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 pts Includes 1 differential diagnosis for the principal diagnosis 0 pts Missing criteria and/or submission. / 5 pts Differential Diagnosis 5 to >3 pts Includes at least 3 differential diagnoses for the principal diagnosis 3 to >1 pts Includes at least 2 differential diagnoses for the principal diagnosis 1 to >0 pts Includes at least 1 differential diagnoses for the principal diagnosis 0 pts Missing criteria and/or submission. / 5 pts ICD 10 Coding 3 to >2 pts Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit 2 to >1 pts Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit 1 to >0 pts Includes some ICD-10 codes relevant to the diagnoses addressed at the visit 0 pts Missing criteria and/or submission. / 3 pts Pharmacologic treatment plan 5 to >3 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 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 pts Includes a detailed pharmacologic 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 pts Diagnostic / Lab Testing 3 to >2 pts Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time” 2 to >1 pts Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time” 1 to >0 pts Includes appropriate diagnostic testing less than 50% of the time. 0 pts Missing criteria and/or submission. / 3 pts Education 3 to >2 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 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 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 healthy behaviors into their lives 0 pts Missing criteria and/or submission. / 3 pts Anticipatory Guidance 3 to >2 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 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 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 pts Follow Up Plan 2 to >1 pts Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months) 1 to >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 pts Prescription 3 to >2 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 pts Prescription includes most required components, but is missing 1-2 elements such as quantity to be dispensed or refills 1 to >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 pts Writing Mechanics, Citations, and APA Style 3 to >2 pts Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA style is correct, and writing is free of grammar and spelling errors. 2 to >1 pts Moderately use the literature and other resources to inform their work. Moderately use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail. 1 to >0 pts Ineffectively uses the literature and other resources to inform their work. Ineffectively use of citations and extended referencing. APA style and writing mechanics need serious attention. 0 pts Missing criteria and/or submission. / 3 pts Total Points: 0