SOAP note

Home>Homework Answsers>Nursing homework helpnoteSOAP note pneumonia2 years ago04.12.202320Report issuefiles (2)SoapNoteGradingRubric.pdfMRUMSN5700CSOAPNOTETemplate2023.docxSoapNoteGradingRubric.pdfSoap Note Grading RubricThis sheet is to help you understand what is required, and what the margin remarks mightbe about on your comments of patients. Since most of the comments that you hand in areuniform, this represents what MUST be included in every write-up.1) Identifying Data (__5- 5pts): The opening list of the note. It contains age, sex, race, maritalstatus, etc. The patient complaint should be given in quotes. If the patient has more thanone complaint, each complaint should be listed separately (1, 2, etc.) and each addressed inthe subjective and under the appropriate number.2) Subjective Data (_30__30pts.): This is the historical part of the note. It contains thefollowing:a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors thatmake it better or worse, and associate manifestations. (10pts).b) Review of systems of associated systems, reporting all pertinent positives and negatives(10pts).c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem(10pts). If more than one chief complaint, each should be written in this manner.3) Objective Data(_25_25pt.): Vital signs need to be present. Height and Weight should beincluded where appropriate.a) Appropriate systems are examined, listed in the note and consistent with those identifiedin 2b.(10pts).b) Pertinent positives and negatives must be documented for each relevant system.c) Any abnormalities must be fully described. Measure and record sizes of things (likesmoles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, andnormal/abnormal to describe things. (5pts).4) Assessment (_10__10pts.): All diagnoses should be clearly listed and wordedappropriately with ICD 10 codes. Rationale and Explanation must be evidence based andhave 1-2 in text references to back up you’re reasoning for making your main diagnosisselection. 3 differential diagnoses must be noted, rationale not required but encouraged.5) Plan (_15__15pts.): Be sure to include any teaching, health maintenance and counselingalong with the pharmacological and non-pharmacological measures. If you have more thanone diagnosis, it is helpful to have this section divided into separate numbered sections.Should not be generic information and should be tailored to your patient and their needs /specific diagnosis.6) Subjective/ Objective, Assessment and Management and Consistent (__10_10pts.): Doesthe note support the appropriate differential diagnosis process? Is there evidence that youknow what systems and what symptoms go with which complaints? Theassessment/diagnoses should be consistent with the subjective section and then theassessment and plan. The management should be consistent with the assessment/diagnoses identified.Clarity of the Write-up(__5_5pts.): Is it literate, organized, and complete?TOTAL: __100______Leonardo Trobajo, MSN, APRNP, AGPCNP-BC, AGACNP-BCCLINICAL INSTRUCTOR:Professor at MSN/FNP ProgramMRUMSN5700CSOAPNOTETemplate2023.docxNOTE: All cases must be developed in primary health care, not at the hospital level.(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site: Ciro A. Ramirez/ South FL MD GroupClinical Instructor: Leonardo Trobajo Lobayna, Professor at MSN/FNP ProgramSoap Note # ____ Main Diagnosis ______________PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:Preventive Care:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History:Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is …Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN:Objective Data:VITAL SIGNS:GENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY:ASSESSMENT:(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. Include the in-text reference/s as per APA style 6th or 7th Edition.Differential diagnosis (minimum 3,only differential diagnoses with CD-10 code, no explanation of each one needed)—PLAN:Labs and Diagnostic Test to be ordered (if applicable)· -· -Pharmacological treatment:-Non-Pharmacologic treatment:Education (provide the most relevant ones tailored to your patient)Follow-ups/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010(25th ed.). Print (The 5-Minute Consult Series).image1.pngMRUMSN5700CSOAPNOTETemplate2023.docxNOTE: All cases must be developed in primary health care, not at the hospital level.(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site: Ciro A. Ramirez/ South FL MD GroupClinical Instructor: Leonardo Trobajo Lobayna, Professor at MSN/FNP ProgramSoap Note # ____ Main Diagnosis ______________PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:Preventive Care:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History:Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is …Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN:Objective Data:VITAL SIGNS:GENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY:ASSESSMENT:(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. Include the in-text reference/s as per APA style 6th or 7th Edition.Differential diagnosis (minimum 3,only differential diagnoses with CD-10 code, no explanation of each one needed)—PLAN:Labs and Diagnostic Test to be ordered (if applicable)· -· -Pharmacological treatment:-Non-Pharmacologic treatment:Education (provide the most relevant ones tailored to your patient)Follow-ups/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010(25th ed.). Print (The 5-Minute Consult Series).image1.pngSoapNoteGradingRubric.pdfSoap Note Grading RubricThis sheet is to help you understand what is required, and what the margin remarks mightbe about on your comments of patients. Since most of the comments that you hand in areuniform, this represents what MUST be included in every write-up.1) Identifying Data (__5- 5pts): The opening list of the note. It contains age, sex, race, maritalstatus, etc. The patient complaint should be given in quotes. If the patient has more thanone complaint, each complaint should be listed separately (1, 2, etc.) and each addressed inthe subjective and under the appropriate number.2) Subjective Data (_30__30pts.): This is the historical part of the note. It contains thefollowing:a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors thatmake it better or worse, and associate manifestations. (10pts).b) Review of systems of associated systems, reporting all pertinent positives and negatives(10pts).c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem(10pts). If more than one chief complaint, each should be written in this manner.3) Objective Data(_25_25pt.): Vital signs need to be present. Height and Weight should beincluded where appropriate.a) Appropriate systems are examined, listed in the note and consistent with those identifiedin 2b.(10pts).b) Pertinent positives and negatives must be documented for each relevant system.c) Any abnormalities must be fully described. Measure and record sizes of things (likesmoles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, andnormal/abnormal to describe things. (5pts).4) Assessment (_10__10pts.): All diagnoses should be clearly listed and wordedappropriately with ICD 10 codes. Rationale and Explanation must be evidence based andhave 1-2 in text references to back up you’re reasoning for making your main diagnosisselection. 3 differential diagnoses must be noted, rationale not required but encouraged.5) Plan (_15__15pts.): Be sure to include any teaching, health maintenance and counselingalong with the pharmacological and non-pharmacological measures. If you have more thanone diagnosis, it is helpful to have this section divided into separate numbered sections.Should not be generic information and should be tailored to your patient and their needs /specific diagnosis.6) Subjective/ Objective, Assessment and Management and Consistent (__10_10pts.): Doesthe note support the appropriate differential diagnosis process? Is there evidence that youknow what systems and what symptoms go with which complaints? Theassessment/diagnoses should be consistent with the subjective section and then theassessment and plan. The management should be consistent with the assessment/diagnoses identified.Clarity of the Write-up(__5_5pts.): Is it literate, organized, and complete?TOTAL: __100______Leonardo Trobajo, MSN, APRNP, AGPCNP-BC, AGACNP-BCCLINICAL INSTRUCTOR:Professor at MSN/FNP ProgramMRUMSN5700CSOAPNOTETemplate2023.docxNOTE: All cases must be developed in primary health care, not at the hospital level.(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site: Ciro A. Ramirez/ South FL MD GroupClinical Instructor: Leonardo Trobajo Lobayna, Professor at MSN/FNP ProgramSoap Note # ____ Main Diagnosis ______________PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:Preventive Care:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History:Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is …Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN:Objective Data:VITAL SIGNS:GENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY:ASSESSMENT:(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. Include the in-text reference/s as per APA style 6th or 7th Edition.Differential diagnosis (minimum 3,only differential diagnoses with CD-10 code, no explanation of each one needed)—PLAN:Labs and Diagnostic Test to be ordered (if applicable)· -· -Pharmacological treatment:-Non-Pharmacologic treatment:Education (provide the most relevant ones tailored to your patient)Follow-ups/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010(25th ed.). Print (The 5-Minute Consult Series).image1.pngSoapNoteGradingRubric.pdfSoap Note Grading RubricThis sheet is to help you understand what is required, and what the margin remarks mightbe about on your comments of patients. Since most of the comments that you hand in areuniform, this represents what MUST be included in every write-up.1) Identifying Data (__5- 5pts): The opening list of the note. It contains age, sex, race, maritalstatus, etc. The patient complaint should be given in quotes. If the patient has more thanone complaint, each complaint should be listed separately (1, 2, etc.) and each addressed inthe subjective and under the appropriate number.2) Subjective Data (_30__30pts.): This is the historical part of the note. It contains thefollowing:a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors thatmake it better or worse, and associate manifestations. (10pts).b) Review of systems of associated systems, reporting all pertinent positives and negatives(10pts).c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem(10pts). If more than one chief complaint, each should be written in this manner.3) Objective Data(_25_25pt.): Vital signs need to be present. Height and Weight should beincluded where appropriate.a) Appropriate systems are examined, listed in the note and consistent with those identifiedin 2b.(10pts).b) Pertinent positives and negatives must be documented for each relevant system.c) Any abnormalities must be fully described. Measure and record sizes of things (likesmoles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, andnormal/abnormal to describe things. (5pts).4) Assessment (_10__10pts.): All diagnoses should be clearly listed and wordedappropriately with ICD 10 codes. Rationale and Explanation must be evidence based andhave 1-2 in text references to back up you’re reasoning for making your main diagnosisselection. 3 differential diagnoses must be noted, rationale not required but encouraged.5) Plan (_15__15pts.): Be sure to include any teaching, health maintenance and counselingalong with the pharmacological and non-pharmacological measures. If you have more thanone diagnosis, it is helpful to have this section divided into separate numbered sections.Should not be generic information and should be tailored to your patient and their needs /specific diagnosis.6) Subjective/ Objective, Assessment and Management and Consistent (__10_10pts.): Doesthe note support the appropriate differential diagnosis process? Is there evidence that youknow what systems and what symptoms go with which complaints? Theassessment/diagnoses should be consistent with the subjective section and then theassessment and plan. The management should be consistent with the assessment/diagnoses identified.Clarity of the Write-up(__5_5pts.): Is it literate, organized, and complete?TOTAL: __100______Leonardo Trobajo, MSN, APRNP, AGPCNP-BC, AGACNP-BCCLINICAL INSTRUCTOR:Professor at MSN/FNP ProgramMRUMSN5700CSOAPNOTETemplate2023.docxNOTE: All cases must be developed in primary health care, not at the hospital level.(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site: Ciro A. Ramirez/ South FL MD GroupClinical Instructor: Leonardo Trobajo Lobayna, Professor at MSN/FNP ProgramSoap Note # ____ Main Diagnosis ______________PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:Preventive Care:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History:Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is …Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN:Objective Data:VITAL SIGNS:GENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY:ASSESSMENT:(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. Include the in-text reference/s as per APA style 6th or 7th Edition.Differential diagnosis (minimum 3,only differential diagnoses with CD-10 code, no explanation of each one needed)—PLAN:Labs and Diagnostic Test to be ordered (if applicable)· -· -Pharmacological treatment:-Non-Pharmacologic treatment:Education (provide the most relevant ones tailored to your patient)Follow-ups/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010(25th ed.). 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