Week 4: Problem-Focused SOAP Note

Week 4: Problem-Focused SOAP Note
Criteria Ratings Pts
This criterion is linked to a
Learning Outcomes
(Subjective)
2.5 pts
Accomplished
Symptom analysis is well organized, with C/C,
OLD CART, pertinent negatives, and pertinent
positives. All data needed to support the
diagnosis & differential are present. Is
complete, concise, and relevant with no
extraneous data.
2.5 pts
This criterion is linked to a
Learning Outcome
(Objective)
2.5 pts
Accomplished
Complete, concise, well organized, well
written, and includes pertinent positive and
pertinent negative physical findings. Organized
by body system in list format. No extraneous
data.soap
2.5 pts
This criterion is linked to a
Learning Outcome A
(Assessment)
2.5 pts
Accomplished
Diagnosis and differential dx are correct,
include ICD code, and are supported by
subjective and objective data.
2.5 pts
This criterion is linked to a
Learning Outcome (Plan) 2.5 pts
Accomplished
The plan is organized, complete and supported
with 2 evidence-based references. Addresses
each diagnosis and is individualized to the
specific patient and includes medication
teaching and all 5 components: (Dx plan, Tx
plan, patient education, referral/follow-up,
health maintenance).