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SOAP NOTE 1: PEDIATRIC

1. SOAP Notes: Students must submit at least four SOAP notes, 1 weekly beginning the third week of the semester. These notes should be de-identified with no protected patient data included. Each note should have a different diagnosis to show the variety of the visits the student is experiencing. These will receive remarks from seminar leaders and should show progression throughout the semester. If the seminar leader feels there is not enough progression the student will be required to continue to turn in notes until proficiency has been reached.

SOAP Note Rubric

Key points: SOAP = Subjective, Objective, Assessment, and Plan. A common mistake students make is to combine the ROS (review of systems) with the physical exam. However, the ROS is subjective—what the patient tells you. The PE is objective: your observation through examining the patient. The ROS belongs in the Subjective portion and the Physical exam belongs in the Objective portion of the note. For assessment section please provide additional differential diagnoses of what the patient might be presenting with, making note of the actual diagnosis form the list of differentials.

Use OLDCARTS for history of present illness:

OLDCARTS   Onset; Location; Duration; Characteristic; Alleviating and aggravating factors; Radiation or relieving factors; Timing; and Severity. 

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SOAP Note Rubric

Key points: SOAP = Subjective; Objective; Assessment; Plan. A common mistake that students make is to combine the ROS (review of systems) with the physical exam. However, the ROS is subjective—what the patient tells you. The PE is objective: your observation through examining the patient. The ROS belongs in the Subjective portion and the PE belongs in the Objective portion of the note. For 693 passing for SOAP notes is 80% or higher.

SOAP Note Rubric

Element

Exceeds Expectations

≥ 90

Meets Expectations 83-89

Partially Meets Expectations 80-82

Does not meet Expectations ≤ 79

SUBJECTIVE

History of Present Illness

(HPI*)

25%

Appropriate OLDCARTS all

discussed, succinct and complete

“Story” of HPI clear and succinct

Appropriate OLDCARTS discussed, extraneous elements included or not succinct

Missing 1-2 pertinent elements

Missing more than 2 pertinent elements

Review of Systems

7.5%

All appropriate systems covered completely, no extraneous

All appropriate systems covered with some extraneous elements

Missing 1 appropriate system

Missing more than 1 appropriate system

Past Medical & surgical History (PMH, PSH) relevant to the HPI Include pertinent history (with positives and negatives)

Allergies LMP

Complete problem list of main problems with relevant PMH/PSH to the HPI explored fully

Includes pertinent negatives as well

1 element in PMH relevant to HPI missing or not explored fully

2 elements in PMH relevant to the HPI missing

Multiple elements in PMH relevant to the HPI missing

2.5%

Family History

(for a focused SOAP, fam hx relevant to the HPI should be explored, a complete list not indicated)

1%

Family history relevant to the HPI included

If nothing relevant- can say “Fhx non- contributory”

Family history missing one to two pertinent elements

Family history missing more than two pertinent elements

Not addressed

Social History

(for a focused SOAP, social history relevant to the HPI should be explored, a complete list not indicated)

1.5%

Social history relevant to the HPI covered completely

Social history missing one pertinent element

Social history missing 2 or more pertinent elements

Not addressed

OBJECTIVE

Physical Examination (can include diagnostic tests or in clinic tests such as pregnancy test- if applicable)

Appropriate based on complaint with no unrelated exam components

Appropriate based on complaint with some unrelated elements

Missing 2 or less elements or 1 inappropriate exam done

Missing more than 2 elements with more than 1 inappropriate element done

10%

ASSESSMENT

Differential Diagnosis (DDx) and Main Dx for each problem

Minimum of 3 differentials diagnosis supported by S + O data and rationale as to why that was or was not chosen for the final Dx

DDX and Main Dx appropriate based on findings with complete reasoning, appropriate ICD-10 and CPT

coding for main Dx

Main Dx Appropriate based on findings though missing 1 key DDx

Rationale for DDX and main Dx could be better described

Appropriate but possible better one available based on findings or missing some key elements

Inappropriate based on findings

27.5%

PLAN

Treatment Plan for each final diagnosis with diagnostics, referrals, pt education, follow-up parameters

Specific, appropriate and EBP with clear explanations for each Dx-with citations from appropriate sources

Appropriate and EBP, Missing a few elements or explanations not clear for all Dx

Missing 1 citation

Appropriate but not first line, or missing multiple minor components

Missing > 1 citation

Inappropriate or missing multiple elements

Missing citations

(each as needed)

Cite reference for

diagnosis and plan for

each problem.

25%

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SOAP NOTE TEMPLATE (Episodic/Problem Visit)

Student Name: Date: Course:

Patient Demographics: (age, gender, ethnicity, etc.)

Chief Complaint: “quote patient”

History of Present illness: 7 attributes required

Past Childhood Illnesses: measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma

PMH: dates in reverse chronological order.

PSH: surgery dates in reverse chronological order.

Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies

Untoward Medication Reactions: include type of reaction/severity/date

Immunization Status: e.g. Flu, Prevnar 13, TdaP, etc. Date must be included

Screenings: e.g. Newborn screening, vision screening, dental visits, TB screening/PPD, etc… (Indicate if results were normal or abnormal)

FMH: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset

Personal History/Social History: family relationship status, children, occupation, living arrangements, exercise, personal interests, religion, illicit drug use, tobacco-use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol use—how many drinks/week, type of alcohol

Females: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced

age of menarche, duration of period, avg. length of cycles, flow, etc

Sexual History: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception

Current Medications/OTCs/Supplements: indicate Dose, Route, Frequency (write class of medication in parentheses):

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.

Review of Systems:

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Breasts:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic:

Hematologic:

Lymphatic:

Endocrine:

Psychiatric:

Screening Tool: ONE screening tool is required and it should be scored (e.g. PHQ-2 Depression Scale, CRAFFT, etc.)—if screening is positive list as a diagnosis with a plan.

For Episodic Visit, only list ROS/PE that are pertinent to CC/HPI.

Physical Exam:

Vital Signs: Blood Pressure- P- RR- T- Pain- Height- Weight- BMI-

General:

Skin:

HEENT:

Head:

Eyes:

Ears:

Nose:

Throat:

Neck:

Breasts:

Lungs:

Heart:

Abdomen:

Genitourinary:

Rectal:

Peripheral Vascular:

Lymphatic:

Extremities: Musculoskeletal:

Neurological:

Pertinent Labs/Diagnostic Testing: Indicate any previous labs or diagnostics done that are relevant to today’s visit, as well as any Point of Care Testing (POCT) done during the visit with results.

Differential Diagnosis Diagnostic Reasoning Exercise: Minimum of 3 differential diagnoses/maximum of 5 differentials—the table will help with the narrative write-up required below the table.

Differential Diagnoses

Pathophysiology

(include APA citations)

Pertinent Positives

Pertinent Negatives

1.

2.

3.

4.

5.

In a narrative format explain how you arrived at your final diagnosis or working diagnoses based on the CC/HPI, PMH, PSH, ROS, & Physical Exam (pertinent +/– will guide this process). This should be written using examples of how the history/clinical presentation led to the final diagnosis or working diagnosis (APA citations to your references must be included – use resources with Evidence Based Guidelines)

Assessment/Plan:

Include a brief summary of the visit here

(APA citations required in your plan)

List diagnoses applicable to your patient encounter. Diagnosis #1 is your primary/working diagnosis made at the time of the visit. If you have not made a diagnosis, then you would use the ICD-10 code for the symptomatology since r/o diagnoses are not billable. This should be followed by a plan of care that is evidenced based.

Diagnosis # 1 ICD-10 (must be related to CC/HPI)

a. Plan listed here (plan should be evidenced based, if not, state why the plan deviated from the evidence)

b.

c.

Diagnosis # 2 ICD-10 may be a chronic condition which is being followed-up (e.g. Asthma, diabetes)

a. Plan listed here

b.

c.

Diagnosis # 3 ICD-10 may be a chronic condition which is being followed-up (e.g. HTN, Asthma)

a. Plan listed here

b.

c.

Health Maintenance: Required App for USPSTF screening guidelines https://epss.ahrq.gov/PDA/index.jsp

Must list all screenings/lifestyle recommendations that are age appropriate (e.g. seasonal flu vaccine, HIV screening; STI screenings, obesity—nutritional/exercise counseling; smoker—tobacco cessation program, etc.)

RTC: (Document disposition)

References (APA Format)

FACULTY ONLY

Grade __________