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Week 4: Problem-Focused SOAP Note
Problem-Focused SOAP Note Format
Demographic Data
• Patient initial (one initial only), age, and gender must be HIPAA compliant.
Subjective
• Chief Complaint (CC)
• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset,
Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors,
Treatment)
• Past Med. Hx (PMH) : Medical or surgical problems, hospitalizations, medications,
allergies, iImmunizations , and preventative health maintenance
• Family Hx
• Social Hx : Including nutrition, exercise, substance use, sexual hx , occupation, school,
etc.
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental,
pap, vaccines, colonoscopy )
Objective
• Physical findings listed by body systems, not paragraph form
Assessment (the diagnosis)
• Three (3) differential diagnosis (if applicable) with rationale
• Final diagnosis with rationale and pathophysiological explanation
Plan
• Dx Plan (lab, x-ray)
• Tx Plan ( meds )
• Pt. Education, including specific medication teaching points
• Referral/Follow-up
• Health maintenance (including when screenings, immunizations, etc., are next due):
Reference
• Compare care given to the patient with the National Standards of Care/National
Guidelines. Cite accordingly.
Rubric
NURS_663L-A_DE – SOAP Note Rubric
NURS_663L-A_DE – SOAP Note Rubric
Criteria Ratings Pts
This criterion is linked to a
Learning Outcome S
(Subject)
7.5 to >6.9 pts
Accomplished
Symptom analysis is well organized, with C/C, OLDCART,
pertinent negatives, and pertinent positives. All data needed
to support the diagnosis & differential are present. Is
complete, concise, relevant with no extraneous data.
7.5
pts
This criterion is linked to a
Learning Outcome O
(Object) 7.5 to >6.9 pts
Accomplished
Complete, concise, well organized
and well written and includes
pertinent positive and pertinent
negative physical findings. Organized
by body system in list format. No
extraneous data.
7.5
pts
This criterion is linked to a
Learning Outcome A (DDX)
7.5 to >6.9 pts
Accomplished
Diagnosis and differential dx are correct with ICD code
and supported by subjective and objective data.
7.5
pts
This criterion is linked to a
Learning Outcome P (Plan)
7.5 to >6.9 pts
Accomplished
Plan is organized, complete and evidence-based according to
National Standards of Care. Addresses each diagnosis and is
individualized to the specific patient and includes medication
teaching and all 5 components: (Dx plan, Tx plan, patient
education, referral/follow-up, health maintenance).
7.5
pts
Total Points: 30