This soap note must be on a patient suffering from a mental health illness. Age 13 and older.
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 patient’s 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 student’s 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 student’s 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.
SOAP Note Rubric 5900 Practicum Series Updated 3.23
SOAP Note Rubric 5900 Practicum Series Updated 3.23
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeChief 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 OutcomeHistory 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 OutcomeMedications
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 OutcomePast 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 OutcomeFamily 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 OutcomePersonal 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 OutcomeReview 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 OutcomeVital 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 OutcomePhysical 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 OutcomeDifferential 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 OutcomeMost 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 OutcomeAssessment 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 OutcomeReferences 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