SOAP note on patient who is 67 years old.
Your SOAP note should be clear and concise; nurse practitioner students will lose points for improper grammar, punctuation, and misspellings. You must use the template provided. Turnitin will recognize the template and not score against it. Your submission will be reviewed for plagiarism through Turnitin. Complete and submit the assignment using the appropriate template in Microsoft Word. Also, the rubric is provided in the template. SOAP NOTE TEMPLATE Review the Rubric for more Guidance Demographics Chief Complaint (Reason for seeking health care) History of Present Illness (HPI) Allergies Review of Systems (ROS) General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: Vital Signs Labs Medications Past Medical History Past Surgical History Family History Social History Health Maintenance/ Screenings Physical Examination General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Diagnosis Differential Diagnosis ICD 10 Coding Pharmacologic treatment plan Diagnostic/Lab Testing Education Anticipatory Guidance Follow up plan Prescription See Below (scroll down) References Grammar Signature (with appropriate credentials):_____________________________________ References (must use current evidence-based guidelines used to guide the care [Mandatory]) EA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________ SOAP Note Rubric Criteria Ratings Pts This criterion is linked to a Learning Outcome Demographics 1 to >0.8 pts Begins with patient initials, age, race, ethnicity and gender (5 demographics) 0.8 to >0.25 pts Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender) 0.25 to >0.0 pts Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) 0 pts Missing criteria and/or submission. 1 pts This criterion is linked to a Learning Outcome Chief Complaint (Reason for seeking health care) 4 to >3.0 pts Includes a direct quote from patient about presenting problem 3 to >2.0 pts Includes a direct quote from patient and other unrelated information 2 to >0.0 pts Includes information but information is NOT a direct quote 0 pts Missing criteria and/or submission. 4 pts This criterion is linked to a Learning Outcome History of the Present Illness (HPI) 5 to >3.0 pts Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 3 to >2.0 pts Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) 2 to Read More