Soap Note 1 pediatrics

This criterion is linked to a Learning OutcomeChief Complaint (CC)The chief complaint (CC) is a concise, one-sentence statement describing the primary reason for the patients visit, including symptom duration. It should be documented in the patients or familys own words whenever possible. Example: Patient reported, “I’ve had a cough and sore throat for two days.”

3 ptsExemplaryClearly stated, includes the reason for the visit, accurately reflects the patients primary concern, is appropriate for the type of write-up, and is documented in the patients or familys own words.2 ptsProficientIncludes the reason for the visit and is appropriate for the type of write-up but is not documented in the patients or familys own words.

1 ptsNeeds ImprovementThe chief complaint (CC) lacks clarity, is not appropriate for the type of write-up, and is not documented in the patients or familys own words.0 ptsNot EvidentNot included.

3 pts

This criterion is linked to a Learning OutcomeHistory of Present Illness (HPI)The History of Present Illness (HPI) utilizes OLD CARTS or PQRST to ensure a thorough assessment of the patients symptoms.

This includes:
Onset: When the symptoms began.
Location: Where the symptom is felt.
Duration: How long it has persisted.
Characteristics: Description of the sensation (sharp, dull, burning, etc.).
Aggravating/Alleviating Factors: What makes it worse or better.
Related Symptoms: Any associated issues.
Treatments: Interventions that have been tried.
Significance: Impact on daily life.

7 ptsExemplaryComprehensive and focused, capturing all relevant details of the current illness and symptoms while omitting unnecessary information. Uses OLD CARTS or PQRST to systematically evaluate all key components, ensuring a thorough and efficient assessment of the patients condition.5 ptsProficientIncludes pertinent information but misses one to two key components or contains some irrelevant details. No objective data included.

3 ptsNeeds ImprovementSuperficial assessment, missing three or more key components, includes irrelevant details, or incorporates objective data inappropriately.0 ptsNot EvidentNot included.

7 pts

This criterion is linked to a Learning OutcomeMedications1. Current Medications: A complete, concise, and well-organized list of all current medications, including prescription, over-the-counter (OTC), and PRN medications. Each medication entry must include:
Drug name, dose, frequency, route, and time of last dose.
Indication (patient-stated reason for taking each medication).
2. Allergies: Medication allergies must be clearly documented, including the specific type of reaction. If no known drug allergies (NKDA), this must be stated.

3 ptsExemplaryA complete, concise, and well-organized summary of all current medications, including drug name, dose, frequency, route, time of last dose, and indication for each medication. Medication allergies are clearly documented, including the type of reaction. AND Food, drug, environmental allergies are clearly documented, including the type of reaction.2 ptsProficientMedication list is included but omits one to two key details. OR Allergies to food and medications are documented, but the type of reaction is missing or NKDA is not recorded.

1 ptsNeeds ImprovementMedication list is present but omits three or more key details. OR Allergies are not documented.0 ptsNot EvidentNot included.

3 pts

This criterion is linked to a Learning OutcomeHistoryA comprehensive history should include:
1. Past medical history (Includes chronic illnesses, hospitalizations, and significant past conditions.)
2. Past Surgical history
3. Family history (Covers 2 generations)
4. Immunization history
5. Allergy history (Documents medication, food, and environmental allergies, including reactions)
6. Personal and Social history
Diet and Exercise
Spirituality/School/Work
Birth History: Reviews prenatal, perinatal, and neonatal details (if applicable).
Exposure History: Screens for TB exposure and lead exposure.
Activities of Daily Living (ADLs) and Habits
Sexual History
Chemical History: Documents smoking, drug use, alcohol consumption, and other substance exposures.

6 ptsExemplaryProvides a comprehensive past medical and surgical history, covering chronic illnesses, hospitalizations, and procedures. Family history extends two generations, identifying hereditary conditions. Immunization and allergy history are reviewed for completeness and accuracy. Social history includes diet, exercise, spirituality, school/work, birth details, TB and lead exposure, ADLs, habits, sexual activity, and substance use.4 ptsProficientHistory is provided but superficial or omits two to three key details from medical, family, immunization, or social history.

2 ptsNeeds ImprovementHistory is superficial and omits three or more key details from medical, family, immunization, or social history.0 ptsNot EvidentNot included.

6 pts

This criterion is linked to a Learning OutcomeGrowth and DevelopmentA comprehensive growth and development assessment should include:
Physical Growth: Assesses the patients growth, including a plotted height and weight chart (marked for the patient’s measurements and attached in the appendix).
Motor Development: Assesses motor skills and coordination.
Cognitive Development: Examines cognitive abilities and problem-solving skills.
Verbal Development: Assesses language and communication skills.
Social Development: Observes social interactions and behavioral patterns.
Developmental Stages and Stage Identification: Summarizes the patients developmental stages according to Erikson and Piagets theories. Identifies the patients current stage with a clear rationale and assesses whether their development aligns with their chronological age.

3 ptsExemplaryComplete, concise, and well-organized summary of the growth and development assessment. All key components are included, and the growth chart is attached in the appendix.2 ptsProficientWell-organized and accurate summary of the growth and development assessment. No major omissions noted, but minor details may be lacking.

1 ptsNeeds ImprovementPoorly organized and/or incomplete summary of growth and development assessment. One key omission is noted.0 ptsNot EvidentNot included

3 pts

This criterion is linked to a Learning OutcomeReview of Systems (ROS)A thorough Review of Systems (ROS) should include a clear narrative assessment of the following systems:
General
Eyes
Ears/Nose/Throat
Endocrine
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Hematology
Lymph
Integumentary
Neck
Neurological
Musculoskeletal
Psychological

5 ptsExemplaryComplete ROS addressing each system with a clear narrative. Avoids vague terms like “within normal limits.” No objective data included.3 ptsProficientROS is mostly complete but missing two to three systems.

2 ptsNeeds ImprovementROS is incomplete, missing four or more systems.0 ptsNot EvidentNo ROS attempted.

5 pts

This criterion is linked to a Learning OutcomeObjective dataA thorough Objective Data section should include:
1. Vital Signs and Measurements
Blood Pressure (BP)
Temperature (Temp)
Pulse
Respiratory Rate (RR)
Height (with percentile %)
Weight (with percentile %)
Body Mass Index (BMI) (with percentile % and category: normal, overweight, obese, etc.)
2. Physical Examination
General
Eyes/Ears/Nose/Throat
Endocrine
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Hematology/Lymph
Integumentary
Neck
Neurological
Musculoskeletal (include assessment of spine)
Psychological
3. Labs and Diagnostics
Any available lab results or pending diagnostics should be documented.

5 ptsExemplaryIncludes all vital signs and measurements, with BMI properly categorized. Physical exam is complete, covering all required systems. Any available labs or diagnostics are documented appropriately.3 ptsProficientMissing BMI categorization or two to three physical exam components. Labs or diagnostics are included but incompletely documented.

2.14 ptsNeeds ImprovementMissing vital signs, an incomplete physical exam with four or more missing components, and fails to document labs or diagnostics.0 ptsNot EvidentNot included.

5 pts

This criterion is linked to a Learning OutcomeAssessmentThe Assessment section includes a well-organized and prioritized list of differential diagnoses based on the chief complaint (CC), review of systems (ROS), and physical exam (PE). Each differential diagnosis should be supported with subjective and objective data, and rationale.
The most likely (presumptive) diagnosis should be clearly identified, with a justification that includes pathophysiology.

The rationale should explain the inclusion and exclusion of differential diagnoses, demonstrating clinical reasoning. ICD-10 codes must be assigned accurately to all diagnoses

7 ptsExemplaryIncludes more than three differential diagnoses based on the CC, ROS, and PE, with strong subjective and objective data, rationale, and diagnostic testing. The list is well-organized and prioritized using clinical reasoning. Identifies the most likely (presumptive) diagnosis with a clear justification, including pathophysiology. Explains the inclusion and exclusion of differentials. ICD-10 codes are accurate.5 ptsProficientIncludes at least three differential diagnoses with general support but lacks depth in rationale or diagnostic testing. The list is organized and prioritized, though reasoning may be underdeveloped. The presumptive diagnosis has a reasonable but somewhat limited justification, including pathophysiology. ICD-10 codes included but may have minor errors.

3 ptsNeeds ImprovementIncludes fewer than three differential diagnoses or unrelated diagnoses. Support is minimal or unclear, lacking subjective/objective data or diagnostic testing. The list is poorly organized with weak justification for the presumptive diagnosis, and pathophysiology is missing. ICD-10 codes may be missing or incorrect.0 ptsNot EvidentNo effort.

7 pts

This criterion is linked to a Learning OutcomePlanThe Plan outlines a structured approach to patient care, including:
Labs/Tests: Orders appropriate diagnostic tests and notes pending results.
Medications: Prescribes or refills medications with correct dosing and instructions.
Interventions: Incorporates both pharmacological and non-pharmacological treatments.
Referrals: Provides necessary referrals when applicable.
Patient Education: Includes tailored health instructions to support management.
Follow-Up: Specifies the timeline and next steps for continued care.
Rationales: Citations for interventions to ensure evidence-based practice.

7 ptsExemplaryA thorough plan addressing all components, including appropriate diagnostic tests, medications with proper dosing, and a combination of pharmacological and non-pharmacological interventions. Includes necessary referrals, detailed patient education, and a clear follow-up plan. Citations for interventions ensure evidence-based care.5 ptsProficientMostly complete but missing one to two components.

3 ptsNeeds ImprovementPlan is superficial, missing three or more components, or lacks evidence-based support. Citations are missing.0 ptsNot EvidentPlan is not included or inappropriate for the patient visit.

7 pts

This criterion is linked to a Learning OutcomeFormatting/APA

4 ptsExemplaryNo errors in grammar or spelling. No APA errors. Write-up is in proper format.3 ptsProficient1-2 spelling/grammar errors or 1-2 APA errors.

2 ptsNeeds Improvement3-4 spelling/grammar errors OR 3-4 APA errors OR improper format.0 ptsNot Evident5+ spelling/grammar errors OR 5+ APA errors.

4 pts