Submit a Problem-Focused SOAP note here for grading. Review the rubric for more information on how your assignment will be graded. Be sure to use the SOAP note template for your program and view the rubric associated with your program for details on how your assignment will be graded.
When completing your SOAP note, ensure it is clear, concise, and organized. The HPI, ROS, and objective findings should support the diagnosis (DSM-5) and treatment plan. In your MSE, normal is not acceptable. Describe what you are assessing. Prescribed medication should include the name, dosage, route, frequency, indication, quantity, and refills available.
N682L-A SOAP Note Rubric (1)
N682L-A SOAP Note Rubric (1)
Criteria
This
criterion is
linked to a
Learning
OutcomeS
(Subjective)
This
criterion is
linked to a
Learning
OutcomeO
(Objective)
Ratings
10 pts
Accomplished
Symptom analysis is well
organized, with C/C, OLD
CART, pertinent negatives, and pertinent positives. All data needed to support the diagnosis & differential are present. Is complete, concise, and relevant with no extraneous data.
5 pts
Satisfactory
Symptom analysis well
organized with C/C,
OLD CART, pertinent
negatives, and pertinent
positives. Some
extraneous data is
present and/or one
minor data point
missing.
2.5 pts
Needs Improvement
Symptom analysis is
not well organized.
Data is missing. There
is too much
extraneous data and/or
2-3 minor data points
missing
0 pts
Unsatisfactory
Symptom analysis is
inadequate, is not
organized. Objective or
other data is mixed into
the subjective data.
Important data is
missing.
10 pts
Accomplished
Complete, concise, well
organized, well written, and
includes pertinent positive and
pertinent negative physical
findings. Organized by body
system in list format. No
extraneous data.
5 pts
Satisfactory
All relevant exams
were done thoroughly
but extraneous exams
were also done. It is
somewhat organized
in list format.
2.5 pts
Needs Improvement
Symptom analysis is not
well organized. Data is
missing. There is too
much extraneous data
and/or 2-3 minor data
points missing.
0 pts
Unsatisfactory
Omitted important
relevant exams and/or
subjective data are
included. Lacking
organization.
N682L-A SOAP Note Rubric (1)
Criteria
This
criterion is
linked to a
Learning
OutcomeA
(Assessment)
This
criterion is
linked to a
Learning
OutcomeP
(Plan)
Total Points: 40
Ratings
10 pts
Accomplished
Diagnosis and
differential dx are
correct, include ICD
code, and are
supported by
subjective and
objective data.
5 pts
Satisfactory
Diagnosis is correct with
ICD codes and is
supported by subjective
and objective data.
Differential diagnosis
was inaccurate based on
subjective and objective
data.
10 pts
Accomplished
Plan is organized, complete
and supported with 2
evidence-based references.
Addresses each diagnosis
and is individualized to the
specific patient and includes
medication teaching and all
5 components: (Dx plan, Tx
plan, patient education,
referral/follow-up, health
maintenance).
5 pts
Satisfactory
Plan is organized,
complete and evidencebased according to
National Standards of
Care. Addresses each
diagnosis and is
individualized to the
specific patient and
includes medication
teaching but may be
missing 1-2 minor
points.
2.5 pts
Needs Improvement
Diagnosis is correct but
either does not include ICD
code or is missing two or
more important differential
diagnoses according to the
subjective and objective
data provided.
0 pts
Unsatisfactory
Diagnosis is not
correct, is not provided
or is not reflective of
the subjective and
objective data
provided.
2.5 pts
Needs Improvement
Plan is less organized
and not based on
evidence according to
the National Standards of
Care. Does not address
each diagnosis or may
not be individualized to
the specific patient.
Missing medication
teaching or one of the 5
components.
0 pts
Unsatisfactory
No Plan provided or i
not organized. Does
not address all
diagnoses identified
and/or does not
include all 5
components of plan,
including medication
teaching.
PMHNP Problem-Focused SOAP Note
(Use this template for this Assignment)
Demographic Data
o
o
Patient age and Patient’s gender identity
MUST BE HIPAA compliant.
Subjective
Chief Complaint (CC):
o
Place the patient’s CC complaint in Quotes
History of Present Illness (HPI):
o Reason for an appointment today.
o The events that led to hospitalization or clinic visits today.
o Include symptoms, relieving factors, and past compliance or non-compliance
with medications
o Any adverse effects from past medication use
o Sleep patterns – number of hours of sleep per day, early wakefulness, not
being able to initiate sleep, not able to stay asleep, etc.
o Suicide or homicide thoughts present
o Any self-care or Activity of Daily Living (ADL) such as eating, drinking
liquids, self-care deficits or issues noted?
o Presence/description of psychosis (if psychosis, command or non-command)
Past Psychiatric History (PSH):
o Past psychiatric diagnoses
o Past hospitalizations
o Past psychiatric medications use
o Any non-compliance issues in the past?
o Any meds that didn’t work for this patient?
Family History of Psychiatric Conditions or Diagnoses:
o Mother/father, siblings, grandparents, or direct relatives
Social History:
o Include nutrition, exercise, substance use (details of use), sexual
history/preference, occupation (type), highest school achievement, financial
problems, legal issues, children, history of personal abuse (including sexual,
emotional, or physical).
Allergies:
o
to medications, foods, chemicals, and other.
Review of Systems (ROS) (Physical Complaints):
o Any physical complaints by body system? (Respiratory, Cardiac, Renal, etc.)
Objective
Mental Status Exam:
o This is not physical exam.
o Mini-Mental Status Exam (MMSE) – Full exam
Assessment (Diagnosis)
Differentials
o
o
o
Two (2) differential diagnoses with ICD-10 codes.
Must include rationale using DSM-5 Criteria (Required)
Why didn’t you pick these as a major diagnosis?
Working Diagnosis
o
o
Final or working diagnosis (1), with ICD-10 code.
Must include rationale using DSM-5 criteria required – Which symptoms/signs
in the DSM-5 the patient matches mostly)
Plan
Treatment Plan (Tx Plan):
o Pharmacologic: Include full information for each medication(s) prescribed
o Refill Provided: Include full information for each medication(s) refilled
Patient Education:
o including specific medication teaching points
o Was risk versus benefit of current treatment plan addressed for meds or
treatment
o Risk versus benefit of non-FDA approved for working diagnosis – Off-label use
of medication education to patient addressed?
Prognosis:
o Make Decision for prognosis: Good, Fair, Poor
o Provide brief statement lending support for or against the decided prognosis.
Therapy Recommendations:
o Type(s) of therapy recommended.
Referral/Follow-up:
o Did you recommend follow-up with Psychiatrist, PCP, or other specialist or
healthcare professionals?
o When is the subsequent follow-up?
o Include rationale for the F/U recommendation or referral.
Reference(s):
o
o
o
Include American Psychological Association (APA) formatted references.
Include a reference from the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Health Disorders (DSM-5) or the accompanying
Desk Reference of Diagnostic Criteria from DSM-5.
Minimum 2 references are required.