use episodic visit for chief complaint These notes should be de-identified with

use episodic visit for chief complaint
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.  
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 the assessment section please provide additional differential diagnoses of what the patient might be presenting with, making note of the actual diagnosis from the list of differentials. 
 
SOAP notes: Students must meet expectations by the final SOAP note or will need to continue to submit SOAP notes until this level of competence is achieved. Passing grade for SOAP notes is 80% or higher.
 
 
Element  
​​Exceeds Expectations ≥ 90​  
Meets Expectations 83-89  
Partially Meets Expectations 80-82  
​​Does not meet Expectations     ≤ 79​  
SUBJECTIVE  
  
  
  
  
History of Present Illness (HPI*). Tell the “story” of the complaint.  
  
  
30%  
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  
Past Medical & surgical History (PMH, PSH) relevant to the HPI  
Include pertinent history (with positives and negatives)  
  
Allergies   
LMP   
  
5%  
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   
Social History  
(for a focused SOAP, social history relevant to the HPI should be explored, a complete list not indicated)  
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  
Family History  
(for a focused SOAP, fam hx relevant to the HPI should be explored, a complete list not indicated)  
5%  
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  
Review of Systems  
  
10%  
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  
OBJECTIVE  
  
  
  
  
Physical Examination  
(can include diagnostic tests or in clinic tests such as pregnancy test- if applicable)  
  
10%  
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  
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  
  
20%  
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  
PLAN  
  
  
  
  
Treatment Plan for each final diagnosis with diagnostics, referrals, patient education, follow-up parameters (each as needed)  
  
Cite reference for diagnosis and plan for each problem.  
  
15%  
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  
* HPI-History of Present Illness. OLDCARTS is often used to help guide covering the key elements of the HPI and refers to Onset, Location, Duration, Character, Associated factors, Relieving factors, Treatment, Severity. Be sure to give the “story” of the symptom or complaint.  
* HPI-History of Present Illness. With pain and many symptoms- an approach that is helpful is OPQRST: Symptom analysis- Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing (history). Or OLDCARTS = Onset, Location, Duration, Character, Alleviating & Aggravating factors, Radiation, Timing, Severity

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