Students must paste their SOAP note under the management plan section of the iHuman system.
Dear Student,
Please make sure to write your SOAP note directly in the Management Plan section within the iHuman platform. It is important that all work is completed within iHuman. Any Word document attachments will not be accepted or graded, so be sure to submit everything through the appropriate platform.
Thank you for your attention to this.*********************************
SUBJECTIVE (15 pts):
CC: “2-3 word description” (1 point)
HPI: **Must write as a paragraph. NO BULLET POINTS. See example. ((10 points)
All: (1 point)
PMH: (1 point)
FMH: (1 point)
MEDS: (1 point)
OBJECTIVE (15 pts): Only include the pertinent systems. Note that CV/Pulm should always be included in all PE.
VS: (1 point)
PE: (see example if needed) (10 points)
Diagnostic Test/labs done: (4 points)
Assessment (15 pts):
Primary Diagnosis & ICD code: (2 points) Rationale (4 points)
i.
DDX#1 w ICD code and rational
(3 points)
ii.
DDX#2 w ICD code and rational
(3 points)
iii.
DDX#3 w ICD code and rational
(3 points)
MEDICATION (10 pts) WRITE as a prescription. Review how to write a prescription.
MEDICATION NAME: (include proper name and strength)
SIG: (this is the directions)
DISP: (this is how many you are giving)
RF: (any refills)
PLAN: 20 points (ALL areas must be included.)
Appropriate Interventions & Referrals: (8 points) **
See example SOAP note if unclear** This section should discuss what you did for the patient during the visit. Key exams required that you did to arrive at the diagnosis. Referrals needed?
Tell me what you did w/ this child in the office (breakdown below; all areas must be included)
· -What Intervention(s)/ treatment(s) in office: (for example-02, sutures, teach to use crutches, Tylenol, (4 Points)
· -Screening tool(s) used: (1 Point)
· -Referral(s) w rational: (1 point) IF NONE, write NONE do not skip
· -Address modifiable risk factors: eg stop smoking, reduce screen time, etc (2 points)
Pt. education (5 points)- – Educate parent and patient about today’s visit/diagnosis/meds etc. Must list a minimum of 5 patient education regarding today’s visit.
1. Pt Ed #1
2. Pt Ed #2
3. Pt Ed #3
4. Pt Ed #4
5. Pt Ed #5
SDOH:
address all 6 areas of social determinants of health (3 points)
1) Economic Stability-
2) Neighborhood-
3) Education-
4) Food Access-
5) Community and Social Context
6) Healthcare System: .
Health Promotion/Anticipatory guidance: (4 points)
Must list a minimum of 4 related to child’s age. Do not simply write f/u on vaccinations, be specific. Use your Bright Futures to help you with this area. *
This is not pt education* See examples.
1) Health Promotion #1
2) Health Promotion #2
3) Health Promotion #3
4) Health Promotion #4
Follow-up: (5 points)
a.
Timing/when: (1 points); Next WCV (1 pt)
b.
Symptom to watch for that will prompt a return (red flags): (3points)
Office BILLING/VISIT CODE and CPT CODES (5 pts)
Clinical Guidelines: 5 points
a. Name of guidelines: (1 points)
b. What does the guidelines tell you to do, or how to make a diagnosis (4 points)
REFERENCES (USE APA)
REFERENCES: SUBJECTED TO UP TO 5 POINT DEDUCTION IF NOT CITED IN YOUR TEXT
Must have 3 and must show that it is cited within your text. Please understand that references provide the information necessary for readers to identify and retrieve each work
cited in the text.
If your references are not cited within your text, then points will be deducted.
**NO MAYO CLINIC, no pt. education websites, CDC should only be for stats. REFERENCES must be peer-reviewed literature. Please utilize the Walden Library. Use primary sources.
