SOAP NOTE- GASTRITIS

The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous weeks learning materials.–GASTRITIS . Review the SOAP Note Rubric. Use a case from the previous weeks discussion or patient from your video submission or clinical practicum experience (adding content as needed to represent abnormal findings). Submit your own note. Do not submit documentation from the patients record. 

RUBRIC

 

SOAP Note Rubric

[SOAP Note Rubric] 100 PointsCriteriaExemplary
Exceeds ExpectationsAdvanced
Meets ExpectationsIntermediate
Needs ImprovementNovice
InadequateTotal Points

Subjective 25%

Information about the patient (3 points)

• Name (initials only); age, and gender
• Source of information; note relationship to patient, if relevant
• Reliability of information

Chief Complaint (1 point)

History of Presenting Illness (8 points)

• Location
• Quality
• Quantity or severity
• Timing (onset, duration, frequency)
• Setting in which it occurs
• Factors that aggravate or relieve the symptoms
• Associated manifestations

Review of Focus System(s) (5 points)

Medications/Allergies (3 points)

History (5 points)

• Past Medical History
• Past Surgical History
• Family History
• Social History
• Health Maintenance Practices

Patient described in appropriate detail

Concise and clear chief complaint as described by patient

HPI includes all components with appropriate detail

Comprehensive review of focus system(s) includes pertinent negatives

Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance;
Allergies to medications and reaction noted

Comprehensive health history is appropriate to reason for visit and includes pertinent negatives

25 pointsPatient described in appropriate detail

Concise and clear chief complaint as described by patient

HPI missing minor detail

Comprehensive review of focus system(s)

Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction noted

Comprehensive health history is appropriate to reason for visit

22 points1 detail missed in patient description

Chief complaint as described by patient, may not be concise or clear

HPI missing 1 component or significant detail

Review of focus system missing 1-2 components

Medication history missing 1-2 components

Health history not appropriate for reason for visit or missing 1-2 components

19 points>2 details missed in patient description

Chief complaint not identified, concise, or clear

HPI missing >2 components and significant detail

Review of focus system(s) missing >3 components

Medication history missing >3 components

Health history missing >3 components

17 points25Objective 30%

Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points)

Appropriate techniques of examination used to identify pertinent findings (10 points)Appropriate areas and systems included in physical assessment

Comprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate

30 points

Missing 1 expected area of assessment

Appropriate techniques of examination used but special assessment technique missed

26 points

Missing 2 expected areas of assessment

One basic technique of examination missed

23 pointsMissing >3 expected areas of assessment

>2 techniques of examination missed

20 points30Assessment 20%

Differential diagnoses are supported by subjective and objective findings (15 points)

Scholarly resources support differential diagnoses (5 points)Three differential diagnoses are supported by findings and include worst case scenario

Rationale for differential diagnoses provided by scholarly resources

20 pointsThree differential diagnoses include worst case scenario but one diagnosis may not be fully supported by findings

Rationale for differential diagnoses provided by scholarly resources

17 pointsDifferential diagnoses may or may not include worst case scenario and 2 differential diagnoses not supported by findings

Rationale for all differential diagnoses not provided by scholarly resources

15 points<3 differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst case scenario

Scholarly resources not provided or do not support differential diagnoses

13 points20Plan 15%

Comprehensive plan to address likely differential diagnosis includes (9 points)

• Diagnostic testing
• Pharmacologic intervention
• Non-pharmacologic intervention
• Referrals
• Patient education
• Follow-up

Plan is supported by appropriate and current practice guidelines (6 points)Comprehensive plan includes all components

Appropriate and current guidelines cited

15 pointsPlan missing 1 of the identified components

Appropriate and current guidelines cited

13 pointsPlan missing 2 of the identified components

Guidelines are not current or appropriate for identified problem

12 pointsPlan missing >3 of the identified components

Guidelines for plan not cited

10 points15Documentation 10%

Documentation follows SOAP template, is logical, and in correct format (10 points)Logical and systematic organization of data

Correct terminology, spelling, and grammar

Scholarly resources noted in correct APA format

10 pointsLogical and systematic organization of data

Terminology, spelling, grammar or format errors (1-3)

8 pointsMinor errors in organization of data

Terminology, spelling, grammar, or format errors (4-5)

7 pointsDisorganized flow of data

Terminology, spelling, grammar or format errors (>5)

6 points10Total Points100