Developing a Focused SOAP Note
This focused SOAP note assignment is a way to reflect on your Practicum experiences and connect them to your classroom experience. Focused SOAP notes are often used in clinical settings to document patient care. They provide a standard, systematic format for collecting patient information. Similar to learning to compute math problems by hand before you move to a calculator, you are required to use a Word document template in this course and document everything manually. In your career, however, you are likely to encounter electronic health record systems with SOAP documentation capabilities such as search functions and symptom drag and drops that will streamline the process.
All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Note, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To prepare:
· Review this week’s Learning Resources, including the Focused SOAP Note Template.
· Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:
· Subjective: What details did the patient provide regarding his or her personal and medical history?
· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
By Day 7
Submit your Assignment. You must submit two files for the SOAP note, including a Word document and scanned pdf/images of each page that is initialed and signed by your preceptor.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the
Turnitin Drafts from the
Start Here area.
1. To submit your completed assignment, save your Assignment as
WK4Assgn1+last name+first initial.
2. Then, click on
Start Assignment near the top of the page.
3. Next, click on
Upload File and select
Submit Assignment for review.
4. Rubric
PRAC_6568_Week4_Assignment1_Rubric
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PRAC_6568_Week4_Assignment1_Rubric |
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Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient you selected. In the Subjective section, provide: • Chief complaint • History of present illness (HPI) • Current medications • Allergies • Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history • Review of systems |
10 to >8.0 ptsExcellentThe response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. 8 to >7.0 ptsGoodThe response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. 7 to >6.0 ptsFairThe response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. 6 to >0 ptsPoorThe response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing. |
10 pts |
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This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
10 to >8.0 ptsExcellentThe response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. 8 to >7.0 ptsGoodThe response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 7 to >6.0 ptsFairDocumentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 6 to >0 ptsPoorThe response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing. |
10 pts |
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This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case. |
25 to >22.0 ptsExcellentThe response lists at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected. 22 to >19.0 ptsGoodThe response lists at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected. 19 to >17.0 ptsFairThe response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 17 to >0 ptsPoorThe response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. |
25 pts |
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This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • Reflections on the case describing insights or lessons learned. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. |
30 to >26.0 ptsExcellentThe response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided. 26 to >23.0 ptsGoodThe response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided. 23 to >20.0 ptsFairThe response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. 20 to >0 ptsPoorThe response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. |
30 pts |
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This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. |
10 to >8.0 ptsExcellentThe response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions. 8 to >7.0 ptsGoodThe response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions. 7 to >6.0 ptsFairThree evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan. 6 to >0 ptsPoorTwo or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan. |
10 pts |
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This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
5 to >4.0 ptsExcellentParagraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.5 ptsGoodParagraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3.5 to >3.0 ptsFairParagraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. 3 to >0 ptsPoorParagraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided. |
5 pts |
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This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
5 to >4.0 ptsExcellentUses correct grammar, spelling, and punctuation with no errors. 4 to >3.5 ptsGoodContains a few (1 or 2) grammar, spelling, and punctuation errors. 3.5 to >3.0 ptsFairContains several (3 or 4) grammar, spelling, and punctuation errors. 3 to >0 ptsPoorContains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
5 pts |
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This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
5 to >4.0 ptsExcellentUses correct APA format with no errors. 4 to >3.5 ptsGoodContains a few (1 or 2) APA format errors. 3.5 to >3.0 ptsFairContains several (3 or 4) APA format errors. 3 to >0 ptsPoorContains many (≥ 5) APA format errors. |
5 pts |
