Assignment Criteria:
Students will complete a Soap note and include the following:
1. Subjective findings
a. Chief complaint (CC)
b. History of present illness (HPI)
i. Use mnemonic (when appropriate): onset, location/radiation, duration, character, aggravating factors, relieving
factors, timing, and severity (OLDCARTS) for acute symptoms
ii. Include pertinent positives and negatives
c. Relevant past medical/surgical/social/family history
d. Medications
i. Allergies, prescription/over the counter (OTC)/herbal medications
e. Relevant review of systems (ROS)
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Objective findings
a. Appropriate physical examination based on subjective findings
b. Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit
c. Screening tools and positive and negative results -
Assessment
a. Correct primary diagnosis
b. Correct differential diagnoses - Correct ICD-10/Current Procedural Terminology (CPT) codes
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Plan
a. Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan
b. Patient education relative to treatment plan.
c. Correctly written out a prescription for one medication prescribed for the patient.
i. If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similarpatient -
Include two current evidence-based guidelines and/or peer-reviewed scholarly journals to support patient education and
treatment plan. The student can pick one evidence-based guideline and one scholarly article. References should be from
scholarly peer-reviewed journals (check Ulrich’s Periodical Directory) and be less than five (5) years old. - APA format required (attention to spelling/grammar, a title page, a reference page, and in-text citations
