The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials- CARPAL TUNNEL SYNDROME . Review the SOAP Note Rubric. Use a case from the previous week’s discussion or patient from your video submission or clinical practicum experience (adding content as needed to represent abnormal findings).RUBRIC:SOAP Note Rubric[SOAP Note Rubric] – 100Subjective – 25%Information about the patient (3 points)Name (initials only); age, and genderSource of information; note relationship to patient, if relevantReliability of informationChief Complaint (1 point)History of Presenting Illness (8 points)LocationQualityQuantity or severityTiming (onset, duration, frequency)Setting in which it occursFactors that aggravate or relieve the symptomsAssociated manifestationsReview of Focus System(s) (5 points)Medications/Allergies (3 points)History (5 points)Past Medical HistoryPast Surgical HistoryFamily HistorySocial HistoryHealth Maintenance PracticesPatient described in appropriate detailConcise and clear chief complaint as described by patientHPI includes all components with appropriate detailComprehensive review of focus system(s) includes pertinent negativesName, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance;Allergies to medications and reaction notedComprehensive health history is appropriate to reason for visit and includes pertinent negatives25 pointsPatient described in appropriate detailConcise and clear chief complaint as described by patientHPI missing minor detailComprehensive review of focus system(s)Name, dose, route, and frequency of prescribed and over-the-counter medications noted, including compliance; Allergies to medications and reaction notedComprehensive health history is appropriate to reason for visit22 points1 detail missed in patient descriptionChief complaint as described by patient, may not be concise or clearHPI missing 1 component or significant detailReview of focus system missing 1-2 componentsMedication history missing 1-2 componentsHealth history not appropriate for reason for visit or missing 1-2 components19 points>2 details missed in patient descriptionChief complaint not identified, concise, or clearHPI missing >2 components and significant detailReview of focus system(s) missing >3 componentsMedication history missing >3 componentsHealth history missing >3 components17 points25Objective – 30%Physical exam includes appropriate areas for Chief Complaint, History of Presenting Illness, and Review of Systems (20 points)Appropriate techniques of examination used to identify pertinent findings (10 points)Appropriate areas and systems included in physical assessmentComprehensive techniques of observation, palpation, percussion, and auscultation noted including special assessments as appropriate30 pointsMissing 1 expected area of assessmentAppropriate techniques of examination used but special assessment technique missed26 pointsMissing 2 expected areas of assessmentOne basic technique of examination missed23 pointsMissing >3 expected areas of assessment>2 techniques of examination missed20 points30Assessment – 20%Differential diagnoses are supported by subjective and objective findings (15 points)Scholarly resources support differential diagnoses (5 points)Three differential diagnoses are supported by findings and include worst case scenarioRationale for differential diagnoses provided by scholarly resources20 pointsThree differential diagnoses include worst case scenario but one diagnosis may not be fully supported by findingsRationale for differential diagnoses provided by scholarly resources17 pointsDifferential diagnoses may or may not include worst case scenario and 2 differential diagnoses not supported by findingsRationale for all differential diagnoses not provided by scholarly resources15 points<3 differential diagnoses identified, or differential diagnoses not supported by findings and do not include worst case scenarioScholarly resources not provided or do not support differential diagnoses13 points20Plan – 15%Comprehensive plan to address likely differential diagnosis includes (9 points)Diagnostic testingPharmacologic interventionNon-pharmacologic interventionReferralsPatient educationFollow-upPlan is supported by appropriate and current practice guidelines (6 points)Comprehensive plan includes all componentsAppropriate and current guidelines cited15 pointsPlan missing 1 of the identified componentsAppropriate and current guidelines cited13 pointsPlan missing 2 of the identified componentsGuidelines are not current or appropriate for identified problem12 pointsPlan missing >3 of the identified componentsGuidelines for plan not cited10 points15Documentation – 10%Documentation follows SOAP template, is logical, and in correct format (10 points)Logical and systematic organization of dataCorrect terminology, spelling, and grammarScholarly resources noted in correct APA format10 pointsLogical and systematic organization of dataTerminology, spelling, grammar or format errors (1-3)8 pointsMinor errors in organization of dataTerminology, spelling, grammar, or format errors (4-5)7 pointsDisorganized flow of dataTerminology, spelling, grammar or format errors (>5)6 points10Total Points100

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