Write a SOAP note about one of your patients and use the following acronym: S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including c

1 to >0.8 pts

Begins with patient initials, age, race, ethnicity and gender (5 demographics)

0.8 to >0.25 pts

Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)

0.25 to >0.0 pts

Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)

0 pts

Missing criteria and/or submission.

4 to >3.0 pts

Includes a direct quote from patient about presenting problem

3 to >2.0 pts

Includes a direct quote from patient and other unrelated information

2 to >0.0 pts

Includes information but information is NOT a direct quote

0 pts

Missing criteria and/or submission.

5 to >3.0 pts

Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

3 to >2.0 pts

Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

2 to >0.0 pts

Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)

0 pts

Missing criteria and/or submission.

2 to >1.5 pts

Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)

1.5 to >1.0 pts

If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy

1 to >0.0 pts

If allergies are present, students lists only the type of allergy name

0 pts

Missing criteria and/or submission.

15 to >8.0 pts

Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”

8 to >3.0 pts

Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies”

3 to >0.0 pts

Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies”

0 pts

Missing criteria and/or submission.

2 to >1.5 pts

Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)

1.5 to >1.0 pts

Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)

1 to >0.0 pts

Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)

0 pts

Missing criteria and/or submission.

2 to >1.5 pts

Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.

1.5 to >1.0 pts

Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.

1 to >0.0 pts

Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.

0 pts

Missing criteria and/or submission.

4 to >2.0 pts

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)

2 to >1.0 pts

Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency)

1 to >0.0 pts

Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)

0 pts

Missing criteria and/or submission.

3 to >2.0 pts

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current

2 to >1.0 pts

Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current

1 to >0.0 pts

Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current

0 pts

Missing criteria and/or submission.

3 to >2.0 pts

Includes, for each surgical procedure, the year of procedure and the indication for the procedure

2 to >1.0 pts

Includes, for each surgical procedure, the year of procedure OR indication of the procedure

1 to >0.0 pts

Includes, for each surgical procedure but not the year of procedure or indication of the procedure

0 pts

Missing criteria and/or submission.

3 to >2.0 pts

Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

2 to >1.0 pts

Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

1 to >0.0 pts

Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.

0 pts

Missing criteria and/or submission.

3 to >2.0 pts

Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

2 to >1.0 pts

Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.

1 to >0.0 pts

Includes 9 or less of the required information.

0 pts

Missing criteria and/or submission.

3 to >2.0 pts

Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least

The post Write a SOAP note about one of your patients and use the following acronym: S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including c first appeared on Nursing StudyMasters.