Students will complete three patient care notes in the SOAP format: 2 for focus assessments and 1 for a comprehensive assessment. The patients to use (in compliance with protecting personal information) will be selected from the student’s clinical rotation.
Assignment Criteria: Format for the SOAP note is as follows
CC – a short statement of the reason for seeking care, can utilize patient words in quotations, if desired
History of Present Illness – includes PQRST information surrounding the chief complaint
Past Medical History – (limited to relevant information for a focus assessment) LMP and parity for women, chronic illnesses/disease, medications, allergies, immunization status, surgeries/procedures, hospitalizations, accidents/injuries, and preventative screening completed.
Family history includes information about disease and living status of primary family.
Social history includes marital status, sexual preference, sexual activity and safety, illicit drug use, alcohol consumption, smoking status, occupation and occupational hazards, safety and security, and stress level.
Review of Systems – (limited to relevant systems for focused assessment.) Designated as subjective by use terms such as “patient states”, “patient reports”, “reports”, “denies”, “notes”, etc.
Constitution, General health and diet
Breast (for women)
GU (female GYN)
Objective – systems should match those in the ROS
General appearance, vital signs
Assessment – includes the Primary Diagnosis and corresponding ICD-10 code with 2-3 Differential Diagnosis and ICD-10 codes. The Primary Diagnosis and Differential Diagnosis need evidential support cited. Chronic, ongoing diagnosis should also be listed last with their corresponding ICD10 codes (these do not need evidential support if the treatment plan or condition has not changed and historical diagnosis are just being reported/recorded).
Plan – includes diagnostic, labs, medications, lifestyle modification, and patient education. All should be supported by literature evidence which is cited.
APA: Title page and Reference list required per APA guidelines. The reference list for cited sources should be on a separate last page – only. Minimum of two original-source references required (not Medscape, 5 Minute Clinical Consult, National Clearinghouse Guidelines, Epocrates). Writing style is medical, not APA. Citations required to support Assessment and Plan. No abstract required. Double-spaced required.