Description
Instructions
Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.
It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.
Each SOAP note carries a 30-point value.
SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.
For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.
For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a ‘0’ will be input into the Grade Center as a place holder until you have submitted the required assignment.
Attached File
SOAP Note Assignment Instructions Download SOAP Note Assignment Instructions[PDF]
SOAP Note Grading RubricDownload SOAP Note Grading Rubric
Rubric
NU631 Unit 6 Assignment – SOAP Note Evaluation Rubric
NU631 Unit 6 Assignment – SOAP Note Evaluation Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeICD-10 Code
2.5 pts
Highly Proficient
ICD-10 Code provided with appropriate modifiers congruent with the clinical information provided
1.5 pts
Marginally Proficient
ICD-10 Code provided with limited clinical information detail
0.5 pts
Not Proficient
ICD-10 code provided is not congruent with the clinical information provided
0 pts
Not evident
ICD-10 Code not provided
2.5 pts
This criterion is linked to a Learning OutcomeE&M CPT Code
2.5 pts
Highly Proficient
Clinical information provided is congruent with and supports the CPT Code identified in the encounter
1.5 pts
Marginally Proficient
Clinical information provided is either not congruent with or does not support the CPT Code identified in the encounter
0.5 pts
Not Proficient
Clinical information provided is not congruent with and does not support the CPT Code identified in the encounter
0 pts
Not evident
CPT Code not provided
2.5 pts
This criterion is linked to a Learning OutcomeSubjective Data
7.5 pts
Highly Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented and demonstrate consistent information across all aspects represented
6 pts
Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented and demonstrate consistent information across all aspects represented
4.5 pts
Marginally Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented but do not demonstrate consistent information across all aspects represented
3 pts
Approaching Proficiency
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are either not satisfactorily documented or do not demonstrate consistent information across all aspects represented
1.5 pts
Not Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented and do not demonstrate consistent information across all aspects represented
0 pts
Not evident
There are elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) that are not provided in the assignment
7.5 pts
This criterion is linked to a Learning OutcomeObjective Data
7.5 pts
Highly Proficient
Elements of objective data are adeptly documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
6 pts
Proficient
Elements of objective data are appropriately documented and demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
4.5 pts
Marginally Proficient
Elements of objective data are satisfactorily documented but do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
3 pts
Approaching Proficiency
Elements of objective data are either not satisfactorily documented or do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
1.5 pts
Not Proficient
Elements of objective data are not satisfactorily documented and do not demonstrate consistency relative to the information documented in the CC, HPI, PMH, and ROS
0 pts
Not evident
There are elements of objective data that are not provided in the assignment
7.5 pts
This criterion is linked to a Learning OutcomeAssessment
5 pts
Highly Proficient
Assessment designations and other elements in this section are adeptly documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data
4 pts
Proficient
Assessment designations and other elements in this section are appropriately documented and demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data
3 pts
Marginally Proficient
Assessment designations and other elements in this section are satisfactorily documented but do not demonstrate congruence with information documented in the CC, HPI, PMH, ROS, and the objective data
2 pts
Approaching Proficiency
Assessment designations and other elements in this section are either not satisfactorily documented or do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data
1 pts
Not Proficient
Assessment designations and other elements in this section are not satisfactorily documented and do not demonstrate congruence of information documented in the CC, HPI, PMH, ROS, and the objective data
0 pts
Not evident
Assessment designations and other elements in this section are not provided in the assignment
5 pts
This criterion is linked to a Learning OutcomePlan
5 pts
Highly Proficient
Elements of the plan are adeptly documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented
4 pts
Proficient
Elements of the plan are appropriately documented, demonstrate application of current clinical practices for the identified assessment designations, and demonstrate congruence of information across all aspects represented
3 pts
Marginally Proficient
Elements of the plan are satisfactorily documented but either do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented
2 pts
Approaching Proficiency
Elements of the plan are either not satisfactorily documented, or do not demonstrate application of current clinical practices for the identified assessment designations, or do not demonstrate congruence of information across all aspects represented
1 pts
Not Proficient
Elements of the plan are not satisfactorily documented, do not demonstrate application of current clinical practices for the identified assessment designations, and do not demonstrate congruence of information across all aspects represented
0 pts
Not evident
Elements of a plan are not provided in the assignment
5 pts
Total Points: 3
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