NUR 634 SOAP Note Guide and Template
\nPatient SOAP Note Charting Procedures
\nS = Subjective
\nO = Objective
\nA = Assessment
\nP = Plan
\nSubjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term \u201csubjective\u201d as opposed to \u201cobjective\u201d. Normally, the practitioner is not aware of this information until the patient provides it.
\nObjective: Information gathered by the treating team or provider which is typically observable and measurable, hence \u201cobjective\u201d as opposed to \u201csubjective\u201d. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient\u2019s posture or gait, and the results of examination procedures and testing.
\nAssessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI.
\nPlan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short- and long-term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded.<\/p>\n
SOAP NOTE TEMPLATE
\n**Please delete the instructions in each section prior to submitting the assignment<\/p>\n
Student Name: \t\tDate:\t\t\t\t Course:<\/p>\n
Subjective:
\nPatient Demographics: (age, gender, gender identity, ethnicity, etc.)
\nChief Complaint: \u201cquote patient\u201d
\nHistory of Present illness: (Be sure to tell the \u201cstory\u201d of the cc using the 7 attributes or OLDCARTS)<\/p>\n
PMH: dates in reverse chronological order.
\nPSH: surgery dates in reverse chronological order.<\/p>\n
Allergies: medications, OTCs, supplements, & environmental\/seasonal\/food allergies
\nUntoward Medication Reactions: include type of reaction\/severity\/date
\nImmunization Status: e.g. Flu, COVID, TdaP, etc.
\nScreenings: In this section you will document any age-appropriate screenings the patient had prior to the visit today. For example, dental visits, PAP, colorectal screening, microfilament, etc\u2026 (Indicate if results were normal or abnormal)
\nFMH: document genetically relevant conditions of immediate family members (parents, children, siblings, and grandparents). If history is unknown, then document \u201chistory unknown\u201d for the family member you inquired about.<\/p>\n
GENOGRAM TO AT LEAST GRANDPARENTS<\/p>\n
Personal History\/Social History: Occupation, home environment, relationship status, nutrition, exercise, and substance use (smoking, alcohol, illicit drug use)<\/p>\n
Females: LMP and relevant OB\/GYN history Gravida, Para, Abortions, Living (G__P__A__L__)
\nIf prior pregnancies document any pregnancy or postpartum complications.<\/p>\n
Sexual History: #of partners, sex of partner\/s, protected\/unprotected sexual relations, contraception<\/p>\n
Current Medications\/OTCs\/Supplements: indicate Dose, Route, Frequency (write either class of medication or indications for use in parentheses)<\/p>\n
For Episodic Visit, only list ROS\/PE that are pertinent to CC\/HPI. Complete a full ROS for a comprehensive\/well exam visit.
\nReview of Systems:
\nGeneral:
\nSkin:
\nHEENT:
\nHead:
\nEyes:
\nEars:
\nNose:
\nThroat:
\nBreasts:
\nRespiratory:
\nCardiovascular:
\nGastrointestinal:
\nGenitourinary:
\nPeripheral Vascular:
\nMusculoskeletal:
\nNeurologic:
\nHematologic:
\nLymphatic:
\nEndocrine:
\nPsychiatric:<\/p>\n
Objective:
\nFor Episodic Visit, only list ROS\/PE that are pertinent to CC\/HPI. Complete a full PE for a comprehensive\/well exam visit.
\nPhysical Exam:
\nVital Signs: Blood Pressure- P- RR- T- Height- Weight- BMI-
\nGeneral:
\nSkin:
\nHEENT:
\nHead:
\nEyes:
\nEars:
\nNose:
\nThroat:
\nNeck:
\nBreasts:
\nLungs:
\nHeart:
\nAbdomen:
\nGenitourinary:
\nRectal:
\nPeripheral Vascular:
\nLymphatic:
\nExtremities: Musculoskeletal:
\nNeurological:<\/p>\n
Assessment:
\nDifferential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential diagnoses\/maximum of 5 differentials\u2014the table will help with the narrative write-up required below the table.<\/p>\n
Differential Diagnoses\tPathophysiology
\n(include Help write my thesis – APA citations)\tPertinent Positives\tPertinent Negatives
\n1.
\n2.
\n3.
\n4.
\n5.<\/p>\n
In a narrative format explain how you arrived at your final diagnosis or working diagnoses based on the CC\/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +\/\u2013 will guide this process). This should be written using examples of how the history\/clinical presentation led to the final diagnosis or working diagnosis (Help write my thesis – APA citations to your references must be included \u2013 use resources with Evidence Based Guidelines)<\/p>\n
Plan:
\nInclude a brief summary of the visit here<\/p>\n
(Help write my thesis – APA citations required in your plan)
\nIn this section, you would list the diagnosis that you assessed for your patient. The Diagnosis is your primary\/working diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the ICD-10 code for the symptomatology since r\/o diagnoses are not billable. This should be followed by a plan of care that is evidenced based.<\/p>\n
Diagnosis ICD-10 (must be related to CC\/HPI)
\n\u2022\tTreatment
\n\u2022\tLab\/test
\n\u2022\tReferral
\n\u2022\tEducation
\n\u2022\tFollow up
\nHealth Maintenance: Required App for USPSTF screening guidelines https:\/\/epss.ahrq.gov\/PDA\/index.jsp
\nMust list all screenings\/lifestyle recommendations that are age appropriate (e.g. seasonal flu vaccine, HIV screening; STI screenings, obesity\u2014nutritional\/exercise counseling; smoker\u2014tobacco cessation program, etc. even though you may not address in an episodic visit)<\/p>\n
RTC: (Document disposition)<\/p>\n
References (Help write my thesis – APA Format)<\/p>\n
NUR 634 SOAP Note Rubric<\/p>\n
Element\tExceeds Expectations \u2265 90\tMeets Expectations 83-89\tPartially Meets Expectations 80-82\tDoes not meet Expectations \u2264 79
\nSUBJECTIVE
\nCC & History of Present Illness
\n(HPI)*
\nTell the \u201cstory\u201d of the complaint
\n30% \tAppropriate OPQRST, the \u201cstory\u201d of the HPI is clear, succinct and complete\tAppropriate OPQRST discussed, extraneous elements included or not succinct\tMissing 1-2 pertinent elements\tMissing more than 2 pertinent elements
\nPast Medical & surgical History (PMH, PSH) relevant to the HPI
\nInclude pertinent history (with positives and negatives)<\/p>\n
Allergies
\nLMP
\nMedications
\n10% \tComplete problem list of main problems with relevant PMH\/PSH to the HPI explored fully<\/p>\n
Include pertinent positives & negatives \t1 element in PMH relevant to HPI missing or not explored fully\t2 elements in PMH relevant to the HPI missing \tMultiple elements in PMH relevant to the HPI missing
\nSocial History
\n\u2022\tIf relevant, include:
\n\u2022\tSexual Hx
\n\u2022\tSubstance use (etoh, drugs, smoking)
\n10% \tSocial history relevant to the HPI covered completely\tSocial history missing one pertinent element\tSocial history missing 2 or more pertinent elements\tNot addressed
\nFamily History
\n5%\tFamily history relevant to the HPI included<\/p>\n
Family history missing one to two pertinent elements\tFamily history missing more than two pertinent elements\tNot addressed
\nReview of Systems<\/p>\n
10% \tAll appropriate systems covered completely, no extraneous\tAll appropriate systems covered with some extraneous elements\tMissing 1 appropriate system\tMissing more than 1 appropriate system
\nOBJECTIVE
\nPhysical Examination
\n(can include diagnostic tests or in clinic tests such as pregnancy test- if applicable)
\n15% \tAppropriate based on complaint\tAppropriate based on complaint with 1-2 missing systems\tAppropriate based on complaint with > 3-4 missing systems\tMissing > 4 elements
\nASSESSMENT<\/p>\n
Differential Diagnosis (DDx) and Main Dx for each problem<\/p>\n
Minimum of 3 differentials diagnosis:
\nPatho of the problem; pertinent positives and pertinent negatives: supported by S + O data and rationale as to why that was or was not chosen for the final Dx
\n10% \tDDX and Main Dx appropriate based on findings with complete reasoning, patho and pertinent positives and negatives included; appropriate ICD-10 and CPT coding for main Dx
\nMain Dx Appropriate based on findings though missing 1 key DDx<\/p>\n
Rationale for DDX and main Dx could be better described
\nAppropriate but possible better one available based on findings or missing some key elements\tInappropriate based on findings
\nPLAN
\nTreatment Plan for each final diagnosis with diagnostics, referrals, pt education, follow-up parameters (each as needed)<\/p>\n
Include HCM recommendations for this patient (see USPSTF for age-appropriate recommendations)<\/p>\n
Cite reference for diagnosis and plan for each problem.
\n10% \tSpecific, appropriate and EBP with clear explanations for each Dx-with citations from appropriate sources\tAppropriate and EBP,
\nMissing a few elements or explanations not clear for all Dx<\/p>\n
Missing 1 citation\tAppropriate but not first line, or missing multiple minor components<\/p>\n
Missing > 1 citation\tInappropriate or missing multiple elements<\/p>\n
Missing citations
\n* Key: CC = Chief complaint; HPI-History of Present Illness. With pain and many symptoms- an approach that is helpful is OPQRST: Symptom analysis- Onset, Provocation\/Palliation, Quality, Region\/Radiation, Severity, Timing (history). Be sure to give the \u201cstory of the symptom or complaint. However, simply listing each of these will not always tell the complete story of the HPI. Step back, read what you wrote and make sure it is clear and complete.<\/p>\n","protected":false},"excerpt":{"rendered":"
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