Case Study SOAP Note #: Soap Note Component Exceptional (3) Average (2) Below Average (1) Score

 Subjective Subjective assessment of health status is completely
expressed. Includes introductory statement giving an
overview of the patient including age, race, gender, reason for
presentation. CC and HPI are targeted toward the reason for
presentation without the inclusion of extraneous information.
CC is clear. HPI is well-developed (includes thorough
symptom analysis and/or other features appropriate for the
respective presentation. Past Medical, Surgical, Family and
Social History, and Review of Systems are included.
Subjective assessment is missing 1 element needed for
adequate evaluation of patient’s problem.
Subjective assessment is missing 2 elements (or
more) needed for adequate evaluation of the patient’s
problem.Includes irrelevant information.
3
Objective Objective assessment of health status is completely
expressed. Physical exam includes all inconclusive objective
findings relevant to case including complete expression of
additional positive physical findings. Appropriate diagnostic
tests with relevant results and/or positive findings.
Objective assessment is missing an element needed for
adequate evaluation of the patient’s problem. Includes
irrelevant information. Failure to document completely
positive findings and/or results of diagnostic exam.
Two or more elements, needed for adequate
evaluationof a patient’s problem is missing from the
objective assessment. 3
Diagnoses Complete problem list is generated and rationally prioritized.
Diagnoses are supported by respective thorough assessment
documented for each problem. Diagnoses reflect application
of best clinical evidence to subjective and objective
assessments.
Problem list is missing one element or is inappropriately
prioritized, but diagnoses are well-supported by
subjective and objective assessment.
Problem list is missing one element, or is
inappropriately prioritized, and diagnoses are not
sufficiently supported by subjective and objective
assessment.
3
Evidence Identification of current evidence-based guidelines to
assessment, diagnosis, and diagnostics with appropriate
application of evidence, indicating rationale(s) for subjective
data, objective data, principle, and differential diagnoses with
consideration of patient age, ethnicity, risk factors, etc.
Includes only one minor error in the application or
omission of evidence-based guidelines to assessment,
diagnosis, and diagnostics with appropriate application of
evidence, indicating rationale(s) for subjective data,
objective data, principle and differential diagnoses with
consideration of patient’s age, ethnicity, risk factors, etc.
Includes two or more omissions or errors in the
application of evidence-based guidelines to
assessment,diagnosis, and diagnostics with
appropriate application of evidence, indicating
rationale(s) for subjective data, objective data,
principle and differential diagnoses withconsideration
of patient’s age, ethnicity, risk factors, etc.
3
Documentation Documentation is well organized and correctly formatted.
Language is clear with appropriate medical terminology. No
inessential, extraneous, or distracting information. Narratives
are complete and have a logical flow.
Documentation contain minor errors