mini soap note

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.

59 y/o female presents to clinic with RLQ pain.

Dx: appendicitis

Review the rubric for more information on how your assignment will be graded.

Demographic Data

Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC) unless an Annual Physical Exam (APE)
• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)

Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable

• Family Hx: As applicable
• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.

Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

Vital signs

Physical findings listed by body systems, not paragraph form

Assessment (Diagnosis/ICD10 Code)

Include all diagnoses that apply for this visit

Plan

Dx Plan (lab, x-ray)

• Tx Plan: (meds)
• Pt. Education, including specific medication teaching points
• Referral/Follow-up

Health maintenance (including when screenings, immunizations, etc., are next due):

*Based on population focus, some additional details may be required by faculty

Rubric

Mini SOAP Note

Mini SOAP Note

6 pts

6 pts

6 pts

6 pts

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeSubjective	6 to >5.4 ptsAccomplishedAll subjective data is included (HPI, nutrition, meds, allergies, PMH, FH, SH). Is complete, concise, and relevant with no extraneous data.5.4 to >4.8 ptsSatisfactoryMost subjective data is included (HPI, nutrition, meds, allergies, PMH, FH, SH). Some extraneous data is present and/or one minor data point missing.4.8 to >4.2 ptsNeeds ImprovementSubjective data is missing. There is too much extraneous data and/or 2-3 major data points missing4.2 to >0 ptsUnsatisfactorySubjective data is missing or is not organized. Objective or other data is mixed into the subjective data.					6 pts
This criterion is linked to a Learning OutcomeObjective	6 to >5.4 ptsAccomplishedComplete, concise, well organized, and well written with applicable vital signs. Organized by body system in list format. No extraneous data.5.4 to >4.8 ptsSatisfactoryAll relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format. Includes some but not all applicable vital signs or other required information.4.8 to >4.2 ptsNeeds ImprovementOmitted important relevant exams, vital signs, and/or not in list format.4.2 to >0 ptsUnsatisfactoryOmitted important relevant exams, vital signs, and/or subjective data are included. Lacking organization.
This criterion is linked to a Learning OutcomeAssessment	6 to >5.4 ptsAccomplishedPreventative care or applicable coding of visit and ICD10 is correct and includes additionally applicable preventative diagnoses based on age/population-specific recommendations.5.4 to >4.8 ptsSatisfactoryAssessment is correct with ICD10 codes; however, some minor additional applicable preventative diagnoses based on age/ population-specific recommendations are missing4.8 to >4.2 ptsNeeds ImprovementAssessment is correct but either does not include ICD10 code or is missing major additional applicable preventative diagnoses based on age/ population-specific recommendations4.2 to >0 ptsUnsatisfactoryAssessment is not correct or is not provided. Missing applicable preventative diagnoses based on age/population-specific recommendations
This criterion is linked to a Learning OutcomePlan	6 to >5.4 ptsAccomplishedPlan is organized, complete and evidence-based according to National Standards of Care. Individualized to the specific patient and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).5.4 to >4.8 ptsSatisfactoryPlan is organized, complete and evidence-based 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 points4.8 to >4.2 ptsNeeds ImprovementPlan is less organized and not based on evidence according to 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.4.2 to >0 ptsUnsatisfactoryNo plan is provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching.
This criterion is linked to a Learning OutcomeProfessional Documentation, Communication, and Engagement	6 to >5.4 ptsAccomplishedAddresses all instructor /preceptor comments and makes all changes and applies feedback as needed. Maintains a positive attitude toward faculty feedback.5.4 to >4.8 ptsSatisfactoryResponds to and addresses some instructor / preceptor comments or questions and applies most instructor feedback to work. Maintains a positive attitude toward faculty feedback.4.8 to >4.2 ptsNeeds ImprovementResponds to some instructor / preceptor comments or questions but does not apply that feedback to work. A positive attitude toward faculty feedback needs improvement.4.2 to >0 ptsUnsatisfactoryDoes not respond to any instructor / preceptor comments and questions. Does not address instructor /preceptor comments and does not make the needed changes. Fails to respond and communicate with instructor.
Total Points: 30