SOAP 1

SOAP Note should be for an Episodic Adult Illness (Headache) 58 yo Caucasian female

Chief complaint: “Dull headaches”

SOAP NOTE RUBRIC

Subjective Data

Chief complaint:

HPI:

Medications: (Reason for use & length of time used)

Allergies: Drugs/Foods /Environmental

Immunizations:

PMH/Surgical History/Birth History if < 12 months of age

Social History:

Family History:

Review of Systems:

24 Hour Dietary Recall and assessment of the diet ( -3 points if missing)

Objective data documented under subjective data – 2 points for each occurrence.

Objective Data

Vital Signs: (Must include BMI; LMP if female of childbearing age). Pediatric SOAPs must have growth charts

Physical exam: (GYN SOAP must have a complete breast and genitalia exam)

Labs: Obtained at current visit if applicable

Subjective data documented under objective data – 2 points for each occurrence.

Assessment

Differential Diagnoses (Total of 3 appropriate diffs for the chief complaint). Explain how each one was ruled in or out.

Presumptive Diagnosis (#1 must support chief complaint)

Plan: For each diagnosis

1. Prescriptions

2. Education

3. Health promotion

4. Referrals

5. Follow up/further testing

6. Culture: What culture is this patient and how did this apply?

7. Research Article: -5 points if older than 5 years and inappropriate article.

8. Turnitin Originality Score: -10 points if >25% for first submission. -20 points if >50%. A score of zero will be assigned for a TII score >70 (no exceptions). **Turnitin scores > 50% will be assessed closely for plagiarism.

PLEASE REVIEW ATTACHED DOCUMENT FOR MORE DETAILS.

INCLUDE: Research article.

Article is peer-reviewed, published within the last 5 years. Article includes Abstract, Methods, Conclusion, Be highlighted (relevant section in yellow). Article directly supports the medication prescribed for the primary presumptive diagnosis; If not the exact medication, it supports the medication class (e.g., ACE-I for Lisinopril). If supporting a non-medication treatment (e.g., PT), it is included in your treatment plan. Justify the medication for your diagnosis.

At the end of your SOAP note, include:

• Article Title
• Author(s)
• Level of Evidence (use the guide below)

Levels of Evidence

• Level I Randomized Controlled Trial (RCT)
• Level II-1 Controlled trial (no randomization)
• Level II-2 Cohort or case-control study
• Level II-3 Multiple time or historical controls
• Level III Expert opinion/clinical experience

NOTE TO WRITER: Please include PDF of article used and highlight YELLOW the section that supports treatment plan for PRIMARY presumptive diagnosis.