WEEK 9 SOAP NOTE

**PLEASE READ**

YOU WILL BE REWRITING THE PEDIATRIC PSYCH SOAP NOTE

THE WEEK 7 SOAP NOTE IS AN EXAMPLE

APA 7TH STYLE FORMAT

REFERENCES AND TITLE PAGE INCLUDED.

Subjective Data:

The Chief Complaint is clear, concise, and verbatim from pt. History of Present Illness is thorough yet concise and provides a chronological account of symptoms and contextual factors that are sufficiently descriptive (OLDCARTS) to validate Dx per DSM-5 TR criteria. All pertinent negatives are included. A longitudinal course of illness is clear. Current psychiatric medications and responses are included.

Objective Data:

MSE contains the required elements. It is in narrative form and effectively and vividly describes the patients presentation. Concrete examples of all assessment results are included i.e. able to correctly interpret 2/3 simple proverbs to validate documentation of abstract thought intact.”

Assessment:

The differential is pertinent to signs and symptoms, the formulation contains evidence of critical thought and subject knowledge, and reasonable diagnoses are made per DSM-5. Clearly met criteria for diagnoses tendered are explicit in the HPI (History of Present Illness) description and substantiated with the MSE.

Plan:

An evidence-based treatment plan is presented with detailed rationales. The level of detail reflects the students ability to choose treatments based not only on FDA approval or current evidence but also on the nuances and unique characteristics of each. The treatment plan is holistic and comprehensive. There is compelling evidence of the students synthesis of information and critical thought. Includes neurobiology information on the disorder.

Writing, Support, APA:

The format is consistent with the example provided in the course. Clear, recent (5-7 years), scholarly, peer-reviewed support of topics. Minimal grammar, spelling, and punctuation errors. Writing mechanics include minimal awkward or unclear passages but are consistent with formal scholarly work. Minimal errors in APA style manuals listed on the course syllabi.

Check out the South College Library for resources to assist you with your APA formatting:

Rubric

SOAP Note Rubric 5900 Practicum Series Updated 3.23

SOAP Note Rubric 5900 Practicum Series Updated 3.23

CriteriaRatingsPtsThis criterion is linked to a Learning Outcome

Chief Complaint or appropriate health screening visit:

5 pts

Exceeds Expectations

Complete, concise, and well-organized statement of the reason for health care visit.

4 pts

Meets Expectations

Well-organized and accurately states the reason for the healthcare visit.

3 pts

Needs Improvement to Meet Expectations

Poorly organized and/or incomplete statement of the reason for the healthcare visit.

2 pts

Does not meet expectations

Chief complaint not identified; poorly organized introduction.

5 pts

This criterion is linked to a Learning Outcome

History of Present Illness

5 pts

Exceeds Expectations

Complete, concise, and well-organized summary of pertinent information related to the reason for the healthcare visit.

4 pts

Meets Expectations

Well-organized and accurate summary of pertinent information related to the reason for the healthcare visit.

3 pts

Needs Improvement to Meet Expectations

Poorly organized and/or incomplete summary of pertinent information related to the reason for the healthcare visit.

2 pts

Does not meet expectations

Poorly organized, incomplete, and/or inaccurate summary of pertinent information related to the reason for the healthcare visit.

5 pts

This criterion is linked to a Learning Outcome

Medications

5 pts

Exceeds Expectations

Complete, concise, and well-organized summary of current medications; drug, dose, frequency, route, time of last dose included for each drug. Includes patient-stated reason for taking the drug.

4 pts

Meets Expectations

Well organized and accurate summary of current medications; dose, frequency for each drug included.

3 pts

Needs Improvement to meet expectations

Poorly organized and/or incomplete summary of current medications.

2 pts

Does not meet expectations

Poorly organized, incomplete, and/or inaccurate summary of current medications

0 pts

No Marks

5 pts

This criterion is linked to a Learning Outcome

Past Medical History

Past Mental Health History

5 pts

Exceeds Expectations

Complete, concise, and well-organized summary of past medical history; includes significant illnesses, surgeries, and diagnostic studies.

4 pts

Meets Expectations

Well-organized, accurate summary of past medical history. No omissions were noted.

3 pts

Needs improvement to meet expectations

Poorly organized and/or incomplete summary of past medical history. One omission was noted.

2 pts

Does not meet expectations

Poorly organized, incomplete, and/or inaccurate summary of past medical history. More than one omission was noted.

5 pts

This criterion is linked to a Learning Outcome

Family History

Family Mental Health History

5 pts

Exceeds Expectations

Complete, concise, and well-organized summary of family history. Genogram included.

4 pts

Meets Expectations

Well-organized, accurate summary of family history. No omissions were noted.

3 pts

Needs improvement to meet expectations

Poorly organized and/or incomplete summary of family history. One omission noted.

2 pts

Does not meet expectations

Poorly organized, incomplete, and/or inaccurate summary of family history. More than one omission noted.

5 pts

This criterion is linked to a Learning Outcome

Personal and Social History

Include ETOH, Smoking, Substance Abuse

5 pts

Exceeds Expectations

Complete, concise, and well-organized summary of personal and social history.

4 pts

Meets Expectations

Well-organized, accurate summary of personal and social history. No omissions were noted.

3 pts

Needs improvement to meet expectations

Poorly organized and/or incomplete summary of personal and social history. One omission was noted.

2 pts

Does not meet expectations

Poorly organized, incomplete, and/or inaccurate summary of personal and social history. More than one omission was noted.

5 pts

This criterion is linked to a Learning Outcome

Review of Systems including:

General

Eyes

Eyes/Nose/

Throat

Endocrine

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Hematology/

Lymph

Integumentary

Neck

Neurological

Musculoskeletal

Psychological

10 pts

Exceeds Expectations

Complete, concise, and well-organized summary of review of systems.

8 pts

Meets Expectations

Well organized and accurate summary of review of systems. No omissions noted.

6 pts

Needs improvement to meet expectations

Poorly organized and/or incomplete summary of review of systems OR nonsubjective information mixed in OR one omission noted.

5 pts

Does not meet expectations

Poorly organized, incomplete, and/or inaccurate summary of review of systems OR more than one omission noted.

10 pts

This criterion is linked to a Learning Outcome

Vital signs:

Vital signs:

BP

Temp

Pulse

RR

Height

Weight

BMI

Include normal, overweight, obese, etc.

5 pts

Exceeds Expectations

All vital signs, measurements included. BMI is identified and categorized.

4 pts

Meets Expectations

All vital signs, measurements included. BMI is identified but not categorized.

3 pts

Needs improvement to meet expectations

At least one omission noted from vital signs and measurements.

2 pts

Does not meet expectations

More than one omission noted from vital signs and measurements.

5 pts

This criterion is linked to a Learning Outcome

Physical Examination including:

General

Eyes

Ears/Nose/Throat

Endocrine

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Hematology/

Lymph

Integumentary

Neck

Neurological

Musculoskeletal

Psychological

Mental Health Exam

Including:

Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well-groomed?

Level of alertness: Is the patient conscious? If not, can they be aroused? Can they remain focused on your questions and conversation? What is their attention span?

Speech: Is it normal in tone, volume and quantity?

Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?

Awareness of environment, also referred to as orientation: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year?

Mood: How do they feel? You may ask this directly (e.g. “Are you happy, sad, depressed, angry?”). Is it appropriate for their current situation?

Affect: How do they appear to you? This interpretation is based on your observation of their interactions during the interview. Do they make eye contact? Are they excitable? Does the tone of their voice change? Common assessments include: flat (unchanging throughout), excitable, and appropriate.

Thought Process: This is a description of the way in which they think. Are their comments logical and presented in an organized fashion? If not, how off base are they? Do they tend to stray quickly to related topics? Are their thoughts appropriately linked or simply all over the map?

Thought Content: A description of what the patient is thinking about. Are they paranoid? Delusional (i.e. hold beliefs that are untrue)? If so, about what? Phobic?

20 pts

Exceeds Expectations

Complete, concise, and well-organized documentation of physical examination.

16 pts

Meets Expectations

Well organized and accurate documentation of physical examination.

15.5 pts

Needs improvement to meet expectations

Poorly organized and/or incomplete documentation of physical examination OR nonobjective findings mixed in OR missing one system.

12 pts

Does not meet expectations

Poorly organized, incomplete, and/or inaccurate documentation of physical examination OR more than one system omitted (deduct 3 points per omitted system).

20 pts

This criterion is linked to a Learning Outcome

Differential Diagnosis

Include ICD-10

Include rationale for why these are the most likely diagnoses

10 to >9.0 pts

Exceeds Expectations

There is a complete and appropriate differential diagnosis list (>3) which is rationally prioritized. All ICD-10 codes are accurate.

9 to >8.0 pts

Meets Expectations

There is a differential diagnosis list of three diagnoses which is rationally prioritized. All ICD-10 codes are accurate.

8 to >7.0 pts

Needs improvement to meet expectations

Differential diagnosis list with one omitted or inappropriate diagnosis OR rationale not provided for one diagnosis OR one ICD-10 code inaccurate.

7 to >0 pts

Does not meet expectations

Differential diagnosis list with more than one omitted or inappropriate diagnosis OR rationale not provided for more than one diagnosis OR more than one ICD-10 code inaccurate.

10 pts

This criterion is linked to a Learning Outcome

Most likely diagnoses, which includes:

Most likely diagnoses, which includes:

Pathophysiology of the diagnosis

Rationale for the diagnosis

Indicated diagnostic testing to support the diagnosis

Medications and nonpharmacologic treatments for the condition

10 pts

Exceeds Expectations

Most likely diagnosis is identified and supported by synthesis of subjective and objective data. There is an exemplary description of pathophysiology, indicated diagnostic testing, treatment, and teaching which is supported by references.

8 pts

Meets Expectations

Most likely diagnosis is identified and supported by synthesis of subjective and objective data. There is a good description of pathophysiology, indicated diagnostic testing, treatment, teaching which is supported by references.

7.5 pts

Needs improvement to meet expectations

Most likely diagnosis is identified but not supported by a synthesis of subjective and objective data OR there is only a brief description of pathophysiology, indicated diagnostic testing, treatment, and teaching OR this information is not supported by references.

5 pts

Does not meet expectations

Most likely diagnosis is not identified OR there is a no description of pathophysiology, indicated diagnostic testing, treatment, teaching.

10 pts

This criterion is linked to a Learning Outcome

Assessment and Plan

Summary of assessment findings, including both subjective and objective

Plan for diagnostics and treatment, including pharmacologic and nonpharmacologic

10 pts

Exceeds Expectations

Exemplary summary of assessment findings. Specific, appropriate, and justified recommendations (including drug name, dose, route, frequency, and duration of therapy) and non-drug therapy (if indicated) for each identified problem. Prioritization is appropriate. Rationales for recommendations included and appropriate.

8 pts

Meets Expectations

Good summary of assessment findings. Specific, appropriate, and justified recommendations (including drug name, dose, route, frequency, and duration of therapy) and non-drug therapy (if indicated) for each identified problem. Prioritization is appropriate.

7.5 pts

Needs improvement to meet expectations

Brief summary of assessment findings. Prioritization is appropriate. One problem omitted OR information other than what was documented in subjective and objective was used to identify problems OR recommendations are omitted for one problem.

5 pts

Does not meet expectations

Incomplete summary of assessment findings OR priority problem not identified OR problems not prioritized OR omission of more than one problem OR identification of nonexistent problem OR recommendations are omitted for more than one problem.

10 pts

This criterion is linked to a Learning Outcome

References in APA format

5 pts

Exceeds Expectations

Multiple (>2) current references including professional journals and noncommercial (e.g., gov, edu, org) website AND no errors in APA citations or references.

4 pts

Meets Expectations

At least two current references including professional journals and noncommercial (e.g., gov, edu, org) website OR 1-2 minor errors in APA citations or references.

3 pts

Needs improvement to meet expectations

Only one current reference including professional journals and noncommercial (e.g., gov, edu, org) website OR multiple errors in APA citations and references.

2 pts

Does not meet expectations

No current professional references. Based solely on personal opinion or lay literature.

5 pts

Total Points: 100