SOAP Note TemplateEncounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health:
Excellent
Good
Fair Poor
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: ____________________________________________________________
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Social history:
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
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GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
Copyright © MVJ 2018
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
3.
Principal Diagnoses
1.
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2.
Plan
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
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Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
Copyright © MVJ 2018
Copyright © MVJ 2018
Distinguised
Excellent
Fair
Poor
Includes a direct quote from patient about
presenting problem
Includes a direct quote from patient and other
unrelated information
Includes information but information is NOT a
direct quote
Information is completely missing
4 Points
Begins with patient initials, age, race,
ethnicity and gender (5 demographics)
3 Points
Begins with 4 of the 5 patient demographics
(patient initials, age, race, ethnicity and gender)
2 Points
Begins with 3 or less patient demographics
(patient initials, age, race, ethnicity and gender)
Information is completely missing
2 Points
1.5 Points
1 Points
0 Points
Includes the presenting problem and the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors,
Timing and Severity)
Includes the presenting problem and 7 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Includes the presenting problem and 6 of the 8
dimensions of the problem (OLD CARTS –
Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing
and Severity)
Information is completely missing
5 Points
3 Points
2 Points
0 Points
If allergies are present, students lists only the
type of allergy name
Information is completely missing
1 Points
0 Points
Subjective
Chief Complaint (Reason for seeking
health care)
Demographics
History of the Present Illness (HPI)
Allergies
Includes NKA (including = Drug,
If allergies are present, students lists type Drug,
Environemental, Food, Herbal, and/or Latex
environemtal factor, herbal, food, latex name and
or if allergies are present (reports for each
includes severity of allergy OR description of
severity of allergy AND description of
allergy
allergy)
2 Points
Review of Systems (ROS)
1.5 Points
Includes 3 or fewer assessments for each body
Includes 3 or fewer assessments for each body
Includes a minimum of 3 assessments for
each body system and assesses at least 9 system and assesses 5-8 body systems directed to system and assesses less than 5 body systems
chief complaint AND uses the words “admits” directed to chief complaint OR student does not
body systems directed to chief complaint
use the words “admits” and “denies”
and “denies”
AND uses the words “admits” and “denies”
12 Points
6 Points
3 Points
0 Points
Information is completely missing
0 Points
Objective
Vital Signs
Includes all 8 vital signs, (BP (with patient
Includes 7 vital signs, (BP (with patient position), Includes 6 or less vital signs, (BP (with patient
position), HR, RR, temperature (with
HR, RR, temperature (with Fahrenheit or Celsius position), HR, RR, temperature (with Fahrenheit
Fahrenheit or Celsius and route of
and route of temperature collection), weight,
or Celsius and route of temperature collection), Information is completely missing
temperature collection), weight, height, BMI
height, BMI (or percentiles for pediatric
weight, height, BMI (or percentiles for pediatric
(or percentiles for pediatric population) and
population) and pain.)
population) and pain.)
pain.)
2 Points
Labs
Medications
Includes a list of the labs reviewed at the
visit, values of lab results and highlights
abnormal values OR acknowledges no
labs/diagnostic tests were reviewed.
3 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for
the medication (including name, dose, route,
frequency)
1.5 Points
Includes a list of the labs reviewed at the visit,
values of lab results but does not highlight
abnormal values.
1 Points
0 Points
Includes a list of the labs reviewed at the visit but
does not include the values of lab results or
Information is completely missing
highlight abnormal values.
2 Points
1 Points
Includes a list of all of the patient reported
medications and the medical diagnosis for the
medication (including 3 of the 4: name, dose,
medications route, frequency)
Includes a list of all of the patient reported
medications (including 2 of the 4: name, dose,
route, frequency)
0 Points
Information is completely missing
Screenings
Past Medical History
4 Points
Includes an assessment of at least 5
screening tests
2 Points
Includes an assessment of at least 4 screening
tests
3 Points
2 Points
Includes (Major/Chronic, Trauma,
Includes (Major/Chronic, Trauma,
Hospitaliztions), for each medical diagnosis,
Hospitaliztions), for each medical diagnosis,
year of diagnosis and whether the diagnosis either year of diagnosis OR whether the diagnosis
is active or current
is active or current
3 Points
Past Surgical History
Family History
Social History
0 Points
Information is completely missing
1 Points
0 Points
Includes each medical diagnosis but does not
include year of diagnosis or whether the
diagnosis is active or current
Information is completely missing
1 Points
0 Points
Includes, for each surgical procedure, the
Includes, for each surgical procedure, the year of Includes, for each surgical procedure but not the
year of procedure and the indication for the
procedure OR indication of the procedure
year of procedure or indication of the procedure Information is completely missing
procedure
3 Points
Includes an assessment of at least 4 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and
cancer.
3 Points
Includes all of the following: tobacco use,
drug use, alcohol use, marital status,
employment status, current/previous
occupation, sexual orientation, sexually
active, contraceptive use, and living
situation.
3 Points
Physical Examination
2 Points
1 Points
Includes an assessment of at least 3 screening
tests
Includes a minimum of 4 assessments for
each body system and assesses at least 5
body systems directed to chief complaint
12 Points
2 Points
1 Points
0 Points
Includes an assessment of at least 3 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Includes an assessment of at least 2 family
members regarding, at a minimum, genetic
disorders, diabetes, heart disease and cancer.
Information is completely missing
2 Points
1 Points
0 Points
Includes 10 of the 11 following: tobacco use,
Includes 9 or less of the following: tobacco use,
drug use, alcohol use, marital status, employment drug use, alcohol use, marital status, employment
status, current/previous occupation, sexual
status, current/previous occupation, sexual
Information is completely missing
orientation, sexually active, contraceptive use,
orientation, sexually active, contraceptive use,
and living situation.
and living situation.
2 Points
1 Points
0 Points
Includes a minimum of 3 assessments for each
Includes a minimum of 2 assessments for each
body system and assesses at least 4 body systems body system and assesses at least 4 body systems Information is completely missing
directed to chief complaint
directed to chief complaint
6 Points
3 Points
0 Points
Assessment
Diagnosis
Includes a clear outline of the accurate
Includes a clear outline of the accurate diagnoses
principal diagnosis AND lists the remaining
Includes an inaccurate diagnosis as the principal
addressed at the visit but does not list the
Information is completely missing
diagnoses addressed at the visit (in
diagnosis
diagnoses in descending order of priority
descending priority)
5 Points
Differential Diagnosis
3 Points
2 Points
0 Points
Includes at least 3 differential diagnoses for Includes 2 differential diagnoses for the principal Includes 1 differential diagnosis for the principal
Information is completely missing
the principal diagnosis
diagnosis
diagnosis
5 Points
3 Points
Plan
2 Points
0 Points
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Includes a detailed pharmacologic treatment
Includes a detailed pharmacologic treatment plan
Includes a detailed pharmacologic treatment plan
plan for each of the diagnoses listed under
for each of the diagnoses listed under
for each of the diagnoses listed under
“assessment”. The plan includes ALL of
“assessment”. The plan includes less than 4 of
“assessment”. The plan includes 4 of the
the following: drug name, dose, route,
the following: the drug name, dose, route,
following 7: the drug name, dose, route,
frequency, duration and cost as well as education
frequency, duration and cost as well as
frequency, duration and cost as well as education
education related to pharmacologic agent. If
related to pharmacologic agent. If the diagnosis
related to pharmacologic agent. If the diagnosis is
the diagnosis is a chronic problem, student
is a chronic problem, student includes
a chronic problem, student includes instructions
includes instructions on currently prescribed
instructions on currently prescribed medications
on currently prescribed medications as above.
medications as above.
as above.
Information is completely missing
5 Points
Includes appropriate diagnostic/lab testing
100% of the time OR acknowledges “no
diagnostic testing clinically required at this
time”
5 Points
3 Points
2 Points
0 Points
Includes appropriate diagnostic/lab testing 50%
of the time OR acknowledges “no diagnostic
testing clinically required at this time”
Includes appropriate diagnostic testing less than
50% of the time.
Information is completely missing
3 Points
2 Points
0 Points
Includes at least 3 strategies to promote and
develop skills for managing their illness and
at least 3 self-management methods on how
to incorporate healthy behaviors into their
lives.
Includes at least 2 strategies to promote and
develop skills for managing their illness and at
least 2 self-management methods on how to
incorporate healthy behaviors into their lives.
Includes at least 1 strategies to promote and
develop skills for managing their illness and at
least 1 self-management methods on how to
incorporate healthy behaviors into their lives.
Information is completely missing
5 Points
3 Points
2 Points
0 Points
Includes at least 3 primary prevention
strategies (related to age/condition (i.e.
immunizations, pediatric and pre-natal
milestone anticipatory guidance)) and at
least 2 secondary prevention strategies
(related to age/condition (i.e. screening))
Includes at least 2 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 2 secondary prevention
strategies (related to age/condition (i.e.
screening))
Includes at least 1 primary prevention strategies
(related to age/condition (i.e. immunizations,
pediatric and pre-natal milestone anticipatory
guidance)) and at least 1 secondary prevention
strategies (related to age/condition (i.e.
screening))
Information is completely missing
4 Points
Includes recommendation for follow up,
including time frame (i.e. x # of
days/weeks/months)
4 Points
2 Points
Includes recommendation for follow up, but does
not include time frame (i.e. x # of
days/weeks/months)
2 Points
1 Points
0 Points
Does not include follow up plan
0 Points
0 Points
Moderate level of APA precision
Incorrect APA style
Information is completely missing
3 Points
2 Points
1 Points
0 Points
Free of grammar and spelling errors
Writing mechanics need more precision and
attention to detail
Writing mechanics need serious attention
3 Points
2 Points
0 Points
Writing
References
Grammar
High level of APA precision
0 Points
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