soap note

Seidel, H.M., Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S. & Stewart, R.W. & Benedict, W. (2011). Mosby’s Guide to Physical Examination, (7th ed). St. Louis: Mosby.

Description:
FOCUSED SOAP NOTE GRADING RUBRIC
Guidelines:
1-Choose a client from your clinical setting & do a focused history & physical exam (see below for content).
2-Select two professional journal articles
3-Based on data obtained from your client & the readings write a SOAP note.

SUBJECTIVE Analysis (10)
1- Compare & contrast subjective section with literature taking into consideration the following criteria;
a-Identified and collected the necessary data
b-Categorized and organized data using the appropriate format
c-Incorporated all pertinent data/facts
d- Used proper documentation
OBJECTIVE Analysis (10)
1- Compare & contrast objective section with literature taking into consideration the following criteria
a. Identified and collected the necessary data
b. Categorized and organized data using the appropriate format
c .Incorporated all pertinent data/facts
d. Used proper documentation

ASSESSMENT Analysis (35)
1- Compare & contrast subjective section with literature taking into consideration the following criteria
a-Filtered relevant data from irrelevant data
b.-Interpreted relationships/patterns among data
(e.g. noted trends)
c. Integrated information to arrive at diagnosis
d .Identified risk factors
e. Differentials listed & discussed in comparison to actual diagnosis
f. Used proper documentation
PLAN Analysis (35)
1- Compare & contrast subjective section with literature taking into consideration the following criteria
a. Recommended an appropriate plan for each problem
b-Included recommendations for non-drug and drug therapy
c-Included recommendations for monitoring
d- Included health education
e- Included follow up & referrals

1- APA
2- References Current
3- Writing clear, concise
4- Summary/Conclusion
Nota: in additional materials i’ll be sending an example on how this work should be done.

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