module 6 soap note

Demographics

Begins with patient initials, age, race, ethnicity and gender (5 demographics)

1 to >0.8 pts

/1 pts

Chief Complaint (Reason for seeking health care)

Includes a direct quote from patient about presenting problem

4 to >3 pts

/4 pts

History of the Present Illness (HPI)

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

5 to >3 pts

/5 pts

Allergies

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)

2 to >1.5 pts

/2 pts

Review of Systems (ROS)

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

15 to >8 pts

/15 pts

Vital Signs

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.)

2 to >1.5 pts

/2 pts

Labs

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.

2 to >1.5 pts

/2 pts

Medications

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)

4 to >2 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)

2 to >1 pts

Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)

1 to >0 pts

Missing criteria and/or submission.

0 pts

/4 pts

Past Medical History

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current

3 to >2 pts

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current

2 to >1 pts

Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Past Surgical History

Includes, for each surgical procedure, the year of procedure and the indication for the procedure

3 to >2 pts

Includes, for each surgical procedure, the year of procedure OR indication of the procedure

2 to >1 pts

Includes, for each surgical procedure but not the year of procedure or indication of the procedure

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Family History

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

3 to >2 pts

Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

2 to >1 pts

Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Social History

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.

3 to >2 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.

2 to >1 pts

Includes 9 or less of the required information.

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Health Maintenance / Screenings

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

3 to >2 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

2 to >1 pts

Includes minimal assessment of immunization status and health maintenance needs, lacking detail. Includes an assessment of at least 3 screening tests

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Physical Examination

Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint

15 to >8 pts

Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint

8 to >3 pts

Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint

3 to >0 pts

Missing criteria and/or submission.

0 pts

/15 pts

Diagnosis

Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)

5 to >3 pts

Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority

3 to >1 pts

Includes 1 differential diagnosis for the principal diagnosis

1 to >0 pts

Missing criteria and/or submission.

0 pts

/5 pts

Differential Diagnosis

Includes at least 3 differential diagnoses for the principal diagnosis

5 to >3 pts

Includes at least 2 differential diagnoses for the principal diagnosis

3 to >1 pts

Includes at least 1 differential diagnoses for the principal diagnosis

1 to >0 pts

Missing criteria and/or submission.

0 pts

/5 pts

ICD 10 Coding

Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit

3 to >2 pts

Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit

2 to >1 pts

Includes some ICD-10 codes relevant to the diagnoses addressed at the visit

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Pharmacologic treatment plan

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.

5 to >3 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.

3 to >1 pts

Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under assessment. The plan includes less than 4 of the information:

1 to >0 pts

Missing criteria and/or submission.

0 pts

/5 pts

Diagnostic / Lab Testing

Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges no diagnostic testing clinically required at this time

3 to >2 pts

Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges no diagnostic testing clinically required at this time

2 to >1 pts

Includes appropriate diagnostic testing less than 50% of the time.

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Education

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.

3 to >2 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.

2 to >1 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

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Anticipatory Guidance

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))

3 to >2 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))

2 to >1 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))

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Follow Up Plan

Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months)

2 to >1 pts

Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)

1 to >0 pts

Missing criteria and/or submission.

0 pts

/2 pts

Prescription

Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and providers signature and credentials

3 to >2 pts

Prescription includes most required components, but is missing 1-2 elements such as quantity to be dispensed or refills

2 to >1 pts

Prescription is missing 3 or more required components such as patient information, date, or providers signature

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts

Writing Mechanics, Citations, and APA Style

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.

3 to >2 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.

2 to >1 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.

1 to >0 pts

Missing criteria and/or submission.

0 pts

/3 pts