soap notes

Hidradenitis suppurativa (HS)   bilateral armpits SOAP Notes:

Students must submit at least 4 SOAP notes, 1 weekly for the first 4 weeks of the semester. These notes should be de-identified with no protected patient data included. Each note should have a different diagnosis to show the variety of the visits the student is experiencing. These will receive remarks from seminar leaders and should show progression throughout the semester. If the seminar leader feels there is not enough progression the student will be required to continue to turn in notes until proficiency has been reached. Proficiency at this level is at least a 17.

A passing soap or assignment needs a least 83%

Element

10 points

8.3 points

Meets Expectations

5 points

Partially Meets Expectations

0 points

Does not meet Expectations

History of Present Illness

Appropriate OLDCARTS all discussed

Missing 1-2 elements that are pertinent

Missing more than 2 pertinent elements

Not addressed

Review of Systems

All appropriate systems covered completely

All appropriate systems covered with some missing pertinent elements

Missing 1 appropriate system

Missing more than 1 appropriate system

Physical Examination

Appropriate based on complaint

Appropriate but missing 1element

Missing 2 or less elements or 1 inappropriate exam done

Missing more than 2 elements or more than 1 inappropriate element done

Diagnostic Tests

Appropriate based on complaint and EBP

Appropriate based on complaint but not level A or B

Missing elements that should be done

Inappropriate or unsafe ordering

Differential Diagnosis (DDx) and Main Dx for each problem

Minimum of 3 differentials diagnosis

DDX and Main Dx appropriate based on findings with complete reasoning, appropriate ICD-10 and CPT coding for main Dx

Main Dx Appropriate based on findings though missing 1 key DDx

Appropriate but possible better one available based on findings or missing some key elements

Inappropriate based on findings

Diagnostic reasoning

supported by S + O data and rationale as to why that was or was not chosen for the final Dx

Appropriate based on complaint and EBP

Discussion of how arrived to the working diagnosis including pertinent positives and negatives and evidence that supports the working diagnosis

Appropriate based on complaint but not EB and missing elements

Missing most of the elements

Not discussed

Assessment

Appropriate based on findings, appropriate ICD-10 and CPT coding

Appropriate but possible better one available based on findings

Appropriate but incomplete reasoning presented

Inappropriate based on findings

Treatment Plan

Appropriate and EBP

Appropriate but not first line recommendations

Appropriate but unable to verbalize why

Inappropriate

Follow-up Plan

Appropriate

And EBP

Appropriate but not first line recommendations

Not discussed