NURS 663 Week 4: Problem-Focused SOAP Note | Homework Solution
Week 4: Problem-Focused SOAP Note
Problem-Focused SOAP Note Format
Demographic Data
- Patient initial (one initial only), age, and gender must be HIPAA
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 Hx (PMH) : Medical or surgical problems, hospitalizations, medications, allergies, immunizations , and preventative health maintenance
·        Family Hx
- Social Hx : Including nutrition, exercise, substance use, sexual hx , occupation, school,
- 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 )
- Education, including specific medication teaching points
- Referral/Follow-up
- Health maintenance (including when screenings, immunizations, , are next due):
Reference
- Compare care given to the patient with the National Standards of Care/National 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. Problem-Focused SOAP Note |
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 |
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| 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). Problem-Focused SOAP Note |
7.5 pts |
|
| Total Points: 30 | |||
