SOAP NOTE – College Pal

39161To prepare: 

Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note. 
Assignment

Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
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 growth and development or 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?

RUBRIC:
PRAC_6541_Week3_Assignment2_Rubric
PRAC_6541_Week3_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeOrganization of Write-up
30 to >26.0 pts
Excellent
All information organized in logical sequence; follows acceptable format
26 to >23.0 pts
Good
Information generally organized in logical sequence; follows acceptable format
23 to >20.0 pts
Fair
Errors in format; information intermittently organized
20 to >0 pts
Poor
Errors in format; information disorganized
30 pts
This criterion is linked to a Learning OutcomeThoroughness of History
20 to >17.0 pts
Excellent
Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information
17 to >15.0 pts
Good
Documents most pertinent history components; includes critical information
15 to >13.0 pts
Fair
Fails to document most pertinent history components; Lacks some critical information or rambling in history
13 to >0 pts
Poor
Minimal history; critical information missing
20 pts
This criterion is linked to a Learning OutcomeThoroughness of Physical Exam
10 to >8.0 pts
Excellent
Thoroughly documents all pertinent examination components for type of note
8 to >7.0 pts
Good
Documents most pertinent examination components
7 to >6.0 pts
Fair
Documents some pertinent examination components
6 to >0 pts
Poor
Physical examination cursory; misses several pertinent components
10 pts
This criterion is linked to a Learning OutcomeDiagnostic Reasoning
10 to >8.0 pts
Excellent
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes all secondary problems. Cost effective when ordering diagnostic tests
8 to >7.0 pts
Good
Assessment consistent with prior documentation. Clear justification for diagnosis. Notes most secondary problems.
7 to >6.0 pts
Fair
Assessment mostly consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests
6 to >0 pts
Poor
Assessment not consistent with prior documentation. Fails to clearly justify diagnosis or note secondary problems or orders inappropriate diagnostic tests
10 pts
This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education
10 to >8.0 pts
Excellent
Treatment plan and patient education addresses all issues raised by diagnoses, excellent insight into patient’s needs. Evidence based decisions. Cost effective treatment. Reflection is thoughtful and in depth.
8 to >7.0 pts
Good
Treatment plan and patient education addresses most issues raised by diagnoses. Reflection is thoughtful and in depth.
7 to >6.0 pts
Fair
Treatment plan and patient education fail to address most issues raised by diagnoses. … Reflection is brief, vague. and does not discuss anything that would have been done in addition to or differently.
6 to >0 pts
Poor
Minimal treatment plan and/or patient education addressed … Reflection is absent.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation.
10 to >8.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
8 to >7.0 pts
Good
Contains a few (1-2) grammar, spelling, and punctuation errors.
7 to >6.0 pts
Fair
Contains several (3-4) grammar, spelling, and punctuation errors.
6 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed.
10 to >8.0 pts
Excellent
Contains parenthetical/in-text citations and at least 3 evidenced based references are listed.
8 to >7.0 pts
Good
Contains parenthetical/in-text citations and at least 2 evidenced based references are listed
7 to >6.0 pts
Fair
Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed
6 to >0 pts
Poor
Contains no parenthetical/in-text citations and 0 evidenced based references listed.
10 pts
Total Points: 100

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